UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


G     000  005  665     5 


LECTURES 


DISEASES    OF    WOMEN. 


BY  THE  SAME  AUTHOR— LATELY  ISSUED. 


LECTURES  ON  THE 
DISEASES  OF  INFANCY  AND  CHILDHOOD. 

Fourth  American  from  the  Fifth  and  Revised  London  Edition. 

In  one  neat  octavo  volume  of6bG  large  pages,  extra  clot  A,  $4.50  ;  leather,  $5.50. 

This  work  may  now  fairly  claim  the  position  of  a  standard  authority  and  medi- 
cal classic.  Five  editions  in  England,  four  in  America,  four  in  Germany,  and 
translations  in  French,  Danish,  Dutch,  and  Kussinn,  show  how  fully  it  has  met 
the  wants  of  the  profession  by  the  soundness  of  its  views  and  the  clearness  with 
which  they  are  presented.  Few  practitioners,  indeed,  have  had  the  opportunities 
of  observation  and  experience  enjoyed  by  the  author.  In  his  Preface  he  re- 
marks :  "  The  present  edition  embodies  the  results  of  1200  recorded  cases  and  of 
nearly  400  post-mortem  examinations,  collected  from  between  30,000  and  40,000 
children,  who,  during  the  past  twenty-six  years,  have  come  under  my  care,  either 
in  public  or  in  private  practice."  The  universal  favor  with  which  the  work 
has  been  received  shows  that  the  author  has  made  good  use  of  these  unusual 
advantages. 


Of  all  the  English  writers  on  the  diseases 
of  children,  there  is  no  one  so  entirely  satis- 
factory to  us  as  Dr.  West.  For  years  we 
have  held  his  opinions  as  judicial,  and  have 
regarded  him  as  one  of  the  highest  living 
authorities  in  the  difficult  department  of 
medical  science  in  which  he  is  moat  widely 
known.  His  writings  are  characterized  by 
a  sound,  practical,  common  sense,  at  the 
same  time  that  they  bear  the  marks  of  the 
most  laborious  study  and  investigation.  We 
commend  it  to  all  as  a  most  reliable  adviser 
on  many  occasions  when  many  treatises  on 
the  same  subjects  will  utterly  fail  to  help  us. 
It  is  supplied  with  a  very  copious  general 
index,  and  a  special  index  to  the  formulse 
scattered  throughout  the  work. — Bostoji. Med . 
and  Surg.  Journal,  April  26,  1806. 

Dr.  West's  volume  is,  in  our  opinion,  in- 
comparably the  best  authority  upon  the 
maladies  of  children  that  the  practitioner 
can  consult.  Withal,  too — a  minor  matter, 
truly,  but  still  not  one  that  should  be  neg- 
lected— Dr.  West's  composition  possesses  a 
peculiar  charm,  beauty,  and  clearness  of  ex- 
pression, thus  affording  the  reader  much 
pleasure,  even  independent  of  that  which 
arises  from  the  acquisition  of  valuable  truths. 
—  Cincinnati  Journal  of  Medicine,  March, 
1866. 

We  have  long  regarded  it  as  the  most 
scientific  and  practical  book  on  diseases  of 
children,  whioii  has  yet  appeared  in  this 
country. — Buffalo  Medical  Journal. 

Undoubtedly  one  of  the  best  books  on  the 
subject  we  have  ever  seen,  and  we  cheerfully 
recommend  it  to  the  profession. — N.  O.  Mtd. 
Record,  July  1,  1866. 


To  occupy  in  medical  literature,  in  regard 
to  diseases  of  children,  the  enviable  position 
which  Dr.  Watson's  treatise  does  on  the  dis- 
eases of  adults,  is  now  very  generally  as- 
signed to  our  author,  and  his  book  is  in  the 
hands  of  the  profession  everywhere  as  an 
original  work  of  great  value. — Md.  and  Va. 
Med.  and  Surg.  Journal. 

Dr.  West's  works  need  no  recommenda- 
tion at  this  date  from  any  hands.  The  vol- 
ume before  us,  especially,  has  won  for  itself 
a  large  and  well-deserved  popularity  among 
the  profession,  wherever  the  English  tongue 
is  spoken.  Many  years  will  elap.se  before  it 
will  be  replaced  in  public  estimation  by  any 
similar  treatise,  and  seldom  again  will  the 
same  subject  be  discussed  in  a  clearer,  more 
vigorous,  or  pleasing  style,  with  equal  sim- 
plicity and  power. — Charleston  Medical 
Journal  and  Review. 

There  is  no  part  of  the  volume,  no  subject 
on  which  it  treats,  which  does  not  exhibit 
the  keen  perception,  the  clear  judgment,  and 
the  sound  reasoning  of  the  author.  It  will 
be  found  a  most  useful  guide  to  the  young 
practitioner,  directing  him  in  his  manage- 
ment of  children's  diseases  in  the  clearest 
possible  manner,  and  enlightening  him  on 
many  a  dubious  pathological  i)oint,  while  the 
older  one  will  find  in  it  many  a  suggestion 
and  practical  hint  of  great  value. — Brit.  Am. 
Med.  Jonrual. 

Dr.  West's  book  is  the  best  that  has  ever 
been  written  in  the  English  language  on  the 
diseases  of  infancy  and  childhood.  —  Colum- 
bits  Revietv  of  Medicine  and  Surgeri/. 


LECTURES 


DISEASES    OF   WOMEN. 


CHARLES    WEST,    M.D., 

Fellow  of  the  Royal  College  of  Physicians ;  Examiner  in  Midwifery  at  the  University 

of  London;  Physician  to  the  Hospital  for  Sick  Children;  and  formerly 

Physician-Accoucheur  to  St.  Bartholomew's  and 

the  Middlesex  Hospitals, 


irb  Inuritan, 


FROM    THE   THIRD   AND    REVISED   ENGLISH    EDITION. 


PHILADELPHIA: 
HENRY     C.     LEA. 

1867. 


PHILADELPHIA: 
CAXTOJf     PRESS     OF     SHERMAN     t     CO. 


-^v 


/  -/^ 


TO 

PETER  MERE  LATHAM,  M.D., 

PHVSICIAN   EXTRAORDINARY    TO    THE   QUEEN, 
AND     FORMERLY     PHYSICIAN     TO     S  T.    B  A  R  T  H  0  L  0  M  E  W  '  S     HOSPITAL: 

WnO  FIRST  SHOWED  ME  HOW  TO  STUDY, 

AND    HOW    TO    PRACTISE    MEDICINE  ; 

WHO  HAS  OFTEN  GUIDED  ME  BY  HIS  ADVICE, 

STILL    OI'TENEIl   TAUGHT    ME    BY    HIS    EXAMPLE  ; 

AND     WHO     SMOOTHED     BY     HIS     UNWEARIED     KINDNESS 

THE    EARLY    DIFFICULTIES    OF    MY    CAREER  ; 

TO     MY     RESPECTED     TEACHER,     MY     GENEROUS     FRIEND, 

I    MOST    GRATEFULLY,    MOST    AFFECTIONATELY, 

THIS     BOOK. 


ADVERTISEMENT  TO  THE  THIRD  EDITION. 


The  adoption  of  a  somewhat  fuller  page  than  in  the  pre- 
vious editions  has  enabled  me  to  increase  the  matter  without 
adding  to  the  size  of  the  book. 

The  chief  additions  will  be  found  under  the  heads  of 
Uterine  Haematocele  and  Ovarian  Disease :  but  I  have  care- 
fully revised  the  whole  work,  and  added  to  it  wherever 
larger  experience  has  increased  my  knowledge. 


61    WiMPOLE  SrEET, 

April  30,  1864. 


ADVERTISEMENT  TO  THE  SECOND  EDITION! 


The  kind  indulgence  with  which  the  first  part  of  these 
Lectures  was  received  has  ah^eady  rendered  a  new  edition  of 
it  necessary.  A  shorter  time,  too,  than  I  feared  has  sufficed 
for  the  fulfilment  of  my  pledge,  and  the  completion  of  the 
work. 

Many  subjects  that  deserve  a  longer  notice  are  touched 
on  here  but  slightly,  and  others  of  a  purely  surgical  nature 
are  completely  j)assed  over,  for  I  have  not  ventured  to  teach 
concerning  matters  with  reference  to  which  I  feel  myself  to 
be  still  altogether  a  learner ;  while  I  have  always  regarded 
mere  compilation,  uncontrolled  by  large  experience,  as  more 
apt  to  perpetuate  error  than  to  difi'use  truth. 

But  I  have  a  more  agreeable  duty  to  perform  than  that 
of  confessing  my  shortcomings,  and  pleading  in  their  exten- 
uation. To  one  of  my  colleagues  at  St.  Bartholomew's  Hos- 
pital I  have  been  constantly  indebted  wherever  the  aid  of 
the  surgeon  was  necessary;  and  Mr.  Paget's  dexterous  hand, 
and  sound  judgment,  and  ready  friendliness,  were  always 
given  almost  without  the  asking.     Many  cases,  those  es-pe- 


ADVERTISEMENT. 


cially  of  ovarian  disease,  we  observed  and  treated  together; 
and  my  opinions  have  often  been  modified,  and  my  conduct 
influenced  by  his  suggestions.  My  readers  will  reap  the 
benefit;  it  is  for  me,  with  best  and  warmest  thanks,  to  ac- 
knowledge the  obligation. 


61  WiMPOLE  Street, 
October,  1858 


ADVERTISEMENT  TO  THE  FIRST  EDITION 
OF  THE  FIRST  PART. 


These  Lectures  are  a  first  instalment  towards  the  dis- 
charge of  that  debt  which  the  opportunities  of  a  hospital 
and  the  responsibilities  of  a  teacher  impose  upon  me.  A 
second  volume,  which  will  treat  of  all  the  remaining  dis- 
eases of  the  female  system,  will  appear,  if  health  and  strength 
are  spared  me,  within  three  years  from  this  time.  I  have 
published  this  part  separately,  because  I  believe  that  students 
and  junior  practitioners  stand  in  much  need  of  that  help 
which,  with  reference  to  an  important  class  of  these  ailments, 
it  may  perhaps  afford  them. 

To  almost  all  persons  there  is  probably  more  of  pain  than 
of  pleasure  in  looking  back  upon  a  work  on  which  much 
time  and  labor  have  been  expended ;  so  wide  is  in  general 
the  distance  between  the  endeavor  and  its  fulfilment.  To 
myself,  the  consciousness  of  doubt  has  often,  while  engaged 
upon  these  Lectures,  been  very  painful,  and"  the  sense  of  im- 
perfect knowledge  has  pressed  heavily  upon  me,  and  does  so 
still. 


Xll  ADVERTISEMENT. 

I  commend  the  book,  however,  to  the  kindly  judgment  of 
my  professional  brethren,  as  embodying  the  results  of  ten 
years  of  observation  in  the  wards  of  a  hospital,  and  of  the 
honest  attempt  to  gather  from  each  day's  added  experience 
something  more  or  better,  for  the  use  of  those  who  look  to 
me  for  help  and  guidance. 


WiMPOLE  Street, 
April,  1856. 


CONTENTS. 


LECTURE  I. 

FAO£ 

Introductory.     Symptoms  of  Diseases  or  Women,  .        .        .        .17 


LECTURE  II. 

Introductory.     Examination    of    Symptoms,  concluded.     Modes    of 

Examination, 24 


LECTURE  III. 
Menstruation,  and  its  Disorders.     Amenorrhcea, 34 

LECTURE  IV. 
Disorders  of  Menstruation.    Amenorrhcea  concluded.    Menorrhagia,    49 

LECTURE  V. 
Disorders  of  Menstruation.     Dysmenorrhcea, 69 

LECTURE  VL 

Diseases  of  the  Uterus.  Inflammation  and  kindred  Processes. 
Hypertrophy  of  the  Uterus,  and  Acute  Inflammation,      .        .     82 

LECTURE  YIl. 

Inflammatory  Affections  of  the  Uterus.  Chronic  Inflammation 
AND  Ulceration  of  the  Os  Uteri  ;  Examination  of  Different 
Opinions  on  this  Subject, 94 

LECTURE  VIII. 

Chronic  Inflammation  and  its  Results,  continued;  Treatment  of 
THE  Affection;  Cases  considerkd  requiring  Local  Treatment 
of  Ulceration.     Cervical  Leucorrhoea, 112 


XIV  CONTENTS. 


LECTUKE  IX. 

PAOE 

Misplacements  of  the  Uterus.  Prolapsus  Uteri,  and  the  Allied 
Misplacements  of  Yagina,  Bladder,  and  Eectum.  Their  Nature 
AND  Mode  of  Production, 126 


LECTURE  X. 

Misplacements  of  the  Uterus,  continued.  Prolapsus  Uteri,  and 
the  Allied  Misplacements  of  Vagina,  Bladder,  and  Eectum. 
Their  Symptoms  and  Treatment,  .         .        .         .        .         .         .  138 


LECTURE  XL 

Misplacements  of  the  Uterus,  continued.    Versions  and  Flexions. 
Anatomy  and  Pathology  of  Axteversion  and  Retroversion,  and 

OF   THE  corresponding   FlEXIONS.       CONGENITAL   OBLIQUITY,        .  .    159 


LECTURE  XII. 

Misplacements  of  the  Uterus,  continued.     Versions  and  Flexions: 

THEIR  Symptoms,  Diagnosis,  and  Treatment, 170 


LECTURE  XIII. 

Misplacements  of  the  Uterus,  continued.     Inversion  of  the  Uterus.  " 
Ascent  of  the  Uterus, 187 


LECTURE  XIV. 

Uterine    Tumors    and    Outgrowths.     Mucous,  Fibro-Cellular,  and 
Glandular  Polypi.    Mucous  Cysts  of  Uterus.    Fibrinous  Polypi,  205 


LECTURE  XV.  ^ 

Uterine  Tumors   and  Outgrowths.     Fibrous   Tumors:   their  Struc- 
ture, Pathology,  and  Symptoms, 216 


LECTURE  XVI, 

Uterine  Tumors  and  Outgrowths.  Fibrous  Tumors,  continued: 
their  Diagnosis,  and  Deviations  from  Ordinary  Symptoms  :  their 
Prognosis, 232 


LECTURE  XVII. 

Uterine  Tumors  and  Outgrowths.    Fibrous  tumors,  continued  :  their 
Treatment, 244 


CONTENTS.  XV 


LECTUKE  XVIII. 

PAGE 

FiBROTis  Polypi.     Eecurbent  Pibroid  Tumors.    Fattt  Tumors  of  the 
Uterus.     Tubercular  Disease  of  the  Uterus, 259 


LECTURE  XIX. 

Malignant,   or  Cancerous   Diseases  of   the   Uterus  :  their  Morbid 
Anatomy, 276 


LECTURE  XX. 

Malignant,  or  Cancerous  Diseases  of  the  Uterus,  continued  :  their 

Pathology,  Symptoms,  and  Diagnosis, 294 


LECTURE  XXI. 

Malignant,  or  Cancerous  Diseases  of  the  Uterus,  continued  :  their 

Treatment, .316 

LECTURE  XXII. 

Inflammation  of  Uterine  Appendagp^s,  and  of  the  Pelvic  Cellular 
Tissue:  Its  Causes,  Symptoms,  and  Course, 336 

LECTURE  XXIII. 

Inflammation  of  Uterine  Appendages,  etc.,  continued  :  Exceptional 
Cases.  Treatment  of  the  Affection.  Hemorrhage  about  the 
Uterus,  or  Uterine  Hematocele, 353 


LECTURE  XXIV. 

Inflammation  of  the  Ovaries  themselves.  The  Acute  and  Chronic 
Forms  of  the  Disease.  Displacement  of  the  Ovary.  Note  on 
Hernia  of  the  Ovary  and  on  Cysts  of  Uterus, 37f 


LECTURE  XXV. 

Ovarian  Tumors  AND  Dropsy  ;  their  Morbid  Anatomy,  .        .        .        .  391 

f 
LECTURE  XXVI. 

Ovarian  Tumors  and  Dropsy.      Pathology  of  the  Disease  furthkr 

considered  :  its  Course  and  Causes, -iOi'y 

LECTUKE  XXVII. 

Ovarian  Tumors  and  Dropsy;  thkir  SY^u•T0Ms  and  Diagnosis.     Xotk 
ON  Floating  Tumors  of  the  Abdomen, 421 


XVI  CONTENTS. 


LECTUKE  XXVIII. 

PAGE 

Ovarian  Tumors  and  Dropsy  ;  their  Prophylactic  and  Palliative 
Treatment, 437 


LECTUEE  XXIX. 

Ovarian  Tumors  and  Dropsy  ;  their  Treatment,  continued  :  Curative 

Measures, 450 


LECTUKE  XXX. 

Ovarian  Tumors  and  Dropsy  ;  their  Treatment,  continued  :  Extirpa- 
tion OF  THE  Disease, 468 


LECTUKE  XXXI. 
Diseases  of  the  Female  Bladder, 484 

LECTUKE  XXXII. 
Diseases  of  the  Urethra  and  Vagina, 498 

LECTUKE  XXXIII. 
Diseases  of  the  External  Organs  of  Generation, 617 

INDEX, 539 


THE 


DISEASES  OE  WOMEN. 


LECTURE    I. 

INTEODUCTOKY. 

Keview  of  subjects  already  considered  in  the  Lectures  on  Midwifery — Eeasons  for 
having  postponed  the  Study  of  the  Diseases  of  Women — Twofold  Knowledge 
requisite  for  their  study — Dangers  and  mistakes  arising  from  want  of  it — 
Illustrative  cases.  Symptoms  of  these  diseases  furnished  by  disturbance  of 
function,  alteration  of  sensibility,  and  change  of  texture.  Symptoms  of  first 
two  classes  considered. 

Gentlemen  :  Some  of  you,  perhaps,  remember  that  I  endeav- 
ored, at  the  commencement  of  my  Lectures  on  Midwifery,  to 
point  out  to  you  the  various  respects  in  which  the  generative 
system  plaj^s  a  more  important  part  in  the  organism  of  woman 
than  in  that  of  the  man.  I  called  your  attention  to  its  constantly 
recurring  activity,  as  displayed  in  the  periodical  return  of  menstrua- 
tion, to  its  fiir-reaching  influence  as  manifested  in  the  various  phe- 
nomena that  attend  upon  pregnancy  and  labor,  and  to  the  impress 
which  the  whole  body  bears  of  the  s[)ecial  adaptation  of  every  part 
for  the  most  complete  performance  of  its  functions.  I  pointed  out 
to  you,  how,  as  the  child  grows,  the  womb  grows  with  it ;  how  its 
lowly  organized  tissues  become  developed;  its  vessels  increase  in* 
size ;  nerve-matter  is  deposited  Avithin  the  sheaths,  so  delicate  as 
to  have  been  almost  imperceptible  before ;  and  the  uterus  becomes 
at  length  what  old  aiuitomists  have  not  hesitated  to  call  it, — Mira- 
culum  iS'aturje.  And  next  I  described  to  you  the  means  by  which 
all  the  dangers  and  dilliculties  of  parturition  are  surmounted; 
and  then  told  you  how,  all  the  grand  functions  of  the'titerus  being 
thus  completed,  its  tissue  undergoes  degradation  and  decay,  its 
vessels  shrink,  its  nerves  dwindle  to  their  former  .size,  all  the 
emunctories  of  the  body  bearing  their  part  in  the  removal  of  the 
now  useless  materials ;  while,  at  the  same  time,  nature  labors 
to  form  a  new  uterus,  fitted  to  go  once  more  through  the  same 
marvellous  changes,  and  to  answer  the  same  important  cuds.     I 

2 


18  IMPORTANCE    AND    DIFFICULTIES 

entered  then  into  such  details,  not  for  the  purpose  of  exciting  idle 
wonder,  but  in  order  to  lead  you  to  the  obvious  inference  that 
processes  so  complicated  must  be  very  apt  to  become  disordered ; 
that  it  must,  therefore,  be  your  duty,  and  ought  to  be  your  pleasure, 
to  acquaint  yourselves  with  them  and  their  disorders ;  that  you 
might  learn  to  know  what  is  healthful,  to  correct  what  is  contrary 
to  nature,  or  to  render  ills  that  are  unavoidable  as  small  as  possible. 
Thus  convinced,  as  I  trust,  of  the  importance  of  the  study,  you 
have  completed  the  examination  into  the  physiology  of  the  female 
sex,  in  so  far  as  the  reproductive  processes  are  concerned,  and 
have  inquired,  moreover,  into  the  various  circumstances  by  which 
the  generative  organs  are  liable  to  be  disturbed  in  the  performance 
of  their  highest  functions,  the  signs  of  such  disturbance,  and  the 
means  whereby  it  may  be  remedied. 

But,  as  the  generative  system  in  woman  has  functions  that  it 
performs  independent  of  those  highest  offices  which  it  discharges 
when  a  germ  has  been  impregnated,  and  becomes  developed  to  a 
new  being,  so  their  disturbance  is  not  without  serious  influence  on 
the  whole  organism.  The  establishment  of  the  sexual  power  at 
puberty,  and  its  extinction  with  advancing  age,  both  exert  impor- 
tant influence  on  the  constitution  ;  at  both  of  these  epochs  there  is 
an  increased  liability  to  disease,  and  at  the  former  a  marked  in- 
crease in  the  rate  of  mortality.  All  tlirough  the  time  of  sexual 
viijjor  too,  a  thousand  causes  mav  derano;e  the  reijular  recurrence 
of  the  manifestations  of  its  activity,  and  thereby  throw  the  whole 
complex  machinery  of  the  body  into  disorder. 

The  disorders  of  the  sexual  functions,  then,  and  the  way  in  which 
they  react  on  the  general  health,  or  are  acted  on  by  it,  call  mani- 
festly for  some  of  your  attention;  but  even  when  you  have  famil- 
iarized yourselves  with  them  moi^t  completely,  your  acquaintance 
with  the  diseases  of  women  will  be  but  just  beginning,  for  the 
organs  which  subserve  these  functions  may  be  themselves  diseased. 
These  organs,  too,  are  complicated  in  their  structure ;  formed  of 
various  tissues,  but  bound  together  by  sympathies  so  close  that  one 
part  cannot  be  the  seat  of  suflering  without  all  suft'ering  together; 
and  hence  it  is  often  no  easy  task  to  unravel  the  tangled  web  of 
symptoms,  and  to  find  out  where  the  mischief  is,  and  what  it  is, 
to  which  so  many  manifestations  of  disease  are  due. 

I  have  deferred  till  now  inviting  you  to  enter  on  the  study  of 
these  afl'ections,  on  account  of  the  many  difficulties  by  which  it  is 
attended,  and  on  account  of  the  need  you  will  find,  in  pursuing  it, 
of  that  special  knowledge  which  you  have  acquired  while  attend- 
ing lecture^  on  midwifery,  as  well  as  of  that  acquaintance  with 
practical  medicine  which  careful  observation  in  the  wards  of  the 
hospital  can  alone  supply.  Knowledge  of  both  of  these  kinds  is 
equally  necessary ;  the  want  of  the  one  or  of  the  other  is  the  cause 
of  those  two  errors  into  which  practitioners  not  infrequently  fall. 
Some  men  regard  the  local  ailment  as  everything ;  others  almost 
lose  sight  of  its  existence,  and  it  is  difficult  to  say  which  of  these 
two  errors  is  the  more  miscjiievous.     A  woman  applies  to  a  prac- 


OF    STUDY    OF    DISEASES    OF    WOMEN.  19 

titioner  who  is  guilty  of  the  first-mentioned  error,  complaining  of 
painful  and  scanty  menstruation  ;  he  at  once  adopts  mechanical 
means  for  her  relief.  He  introduces  bougies  to  widen  the  canal, 
and  to  remove  some,  perliaps  imaginary,  contraction  of  the  cervix 
uteri,  by  which  he  conceives  the  escape  of  the  menstrual  fluid  to 
be  impeded,  and  he  even  incises  it  to  make  sure  of  enlarging  its 
calibre.  After  undergoing  much  pain  of  body,  and  much  distress 
of  mind,  the  patient  finds  herself  at  the  end  of  these  manipulations 
no  better  than  when  they  began  ;  the  cause  of  her  sufferings  lay 
deeper,  and  was  to  have  been  found  in  the  derangement  of  her 
general  health,  which  would  have  attracted  the  notice  of  a  better 
physician,  and  which  well-directed  measures  would  probably  have 
cured.  Let  me  mention  another  case  as  illustrative  of  the  opposite 
error.  A  patient  seeks  for  relief  on  account  of  profuse  menstrua- 
tion, attended  with  discharge  of  coagula,  but  accompanied  with 
little  or  no  pain.  General  treatment  is  adopted,  the  patient  is  con- 
fined to  the  recumbent  posture,  in  a  cool  and  well-ventilated  room, 
astringents  are  given  internally,  cold  is  applied  locally,  and  no 
sign  of  disorder  of  the  general  health  is  allowed  to  pass  without 
appropriate  means  for  its  cure ;  but  yet  amendment  does  not  follow, 
for  the  bleeding  depends  upon  the  presence  of  a  minute  polypus, 
which  nothing  but  careful  examination  of  the  uterus  could  dis- 
cover. In  the  one  case,  a  crass  mechanical  treatment  was  adopted 
to  cure  an  affection  that  depended  on  the  state  of  the  general 
health ;  in  the  other,  general  treatment  failed  to  remove  symp- 
toms which  careful  investigation  would  have  shown  to  depend 
upon  a  local  cause. 

But  I  need  not  draw  upon  imaginary  cases  in  order  to  enforce 
the  caution  that  I  am  desirous  of  impressing  on  you ;  the  records 
either  of  hospital  or  of  private  practice  afford  illustrations  of  it  in 
abundance. 

A  middle-aged  woman  complained  of  frequent  desire  to  pass 
water,  and  of  discomfort  in  voiding  it;  she  was  dyspeptic  and  out 
of  health.  Her  urine  was  tested,  and  found  to  contain  albumen ; 
and  the  irritable  state  of  her  bladder  was  assumed  to  be  dependent 
on  the  disease  of  her  kidneys.  Treatment  improved  her  general 
health,  but  brought  no  relief  to  her  dysuria.  At  length  careful 
observation  discovered  the  albumen  to  be  due  to  the  admixture  of 
vaginal  discharges  with  her  urine — a  not  infrequent  source  of  it 
in  women  who  suffer  from  leucorrhoea;  while  examination,  which 
had  been  delayed  too  long,  detected  a  small  vascular  tumor  just 
within  the  orifice  of  the  urethra,  to  the  irritation  produced  by 
which  her  symptoms  were  due,  as  was  shown  by  their  immediate 
disappearance  on  its  removal. 

A  young  lady  whose  health  had  never  been  robust,  began  at  the 
age  of  twenty-two  to  menstruate  irregularly  and  scantily,  and  to 
suffer  at  tlie  same  time  from  pruritus  of  tlie  vulva.  For  this 
symptom  various  local  applications  were  resorted  to,  and  more 
than, once  she  underwent  the  distress  of  an  examination  wliich 
discovered  nothing  more  than  an  increased  degree  of  redness 


20        ERRORS    IN    DIAGNOSIS    OF    DISEASES    OF   "WOMEN. 

about  the  labia  and  njmphse.  At  length,  with  the  decline  of  her 
general  health,  she  came  under  the  care  of  another  physician,  who 
ascertained  that  sugar  was  present  in  her  urine.  The  pruritus, 
like  the  itching  of  the  urethra  in  the  male  subject,  was  the  con- 
sequence and  the  symptom  of  the  diabetes  of  which  the  poor  girl 
eventually  died. 

A  woman  was  admitted  into  the  hospital  a  few  years  ago  in  a 
state  of  extreme  sutiering ;  her  countenance  was  very  anxious  ;  she 
lay  in  bed  with  her  knees  drawn  up,  dreading  the  slightest  move- 
ment ;  her  abdomen  Avas  intolerant  even  of  the  slightest  pressure. 
She  was  reputed  to  have  peritonitis,  and  had  been  bled  for  this, 
as  well  as  abundantly  salivated  before  her  admission,  yet  without 
relief.  But  with  all  this  her  skin  was  perspiring,  and  her  pulse 
was  soft,  and  not  increased  in  frequency.  Her  history  was,  that 
after  vague  uterine  ailments  for  a  month,  slie  was  suddenly  attacked 
by  violent  pain  in  the  womb,  attended  witli  bearing-down  efforts 
equal  in  intensity  to  those  of  labor.  These  subsided,  but  the 
pain  was  referred  to  the  bladder,  and  desire  to  pass  water  became 
very  frequent.  This  too  abated,  and  the  next  complaint  was  of 
violent  pain  in  the  shoulder,  which  was  encountered  by  active 
measures  for  the  relief  of  alleged  inflammation  of  the  shoulder- 
joint;  and  the  pain  in  the  shoulder  suddenly  ceasing,  the  severe 
abdominal  suffering  at  once  succeeded  it.  A  hot  hip-bath  gave 
almost  inmiediate  relief,  though  the  patient  screamed  when  moved 
in  order  to  be  placed  in  it ;  and  a  full  dose  of  opium  was  followed 
by  some  hours  of  quiet  sleep.  The  next  day  no  pain  was  com- 
plained of  except  over  the  pubes,  and  this  soon  disappeared  under 
the  use  of  anodynes;  and  steel  and  good  food  completed  tlie  cure 
of  a  case  of  hysterical  peritonitis. 

Now  these  cases,  to  which  it  would  be  very  easy  to  add  many 
more,  are  all  examples  of  the  error  of  making  too  little  or  too 
much  of  symptoms  indicating  disorder  of  the  sexual  system.  Your 
general  medical  knowledge  must  keep  you  from  the  latter;  it  is 
my  special  dutj-  to  arm  you  against  the  former,  or  rather,  as  much 
as  in  me  lies,  to  defend  you  from  both. 

With  this  view  I  propose  to-day  to  make  a  few  introductory 
remarks  upon  the  signs  and  symptoms  of  disease  of  tlie  generative 
organs  in  the  female,  and  on  the  means  of  investigating  them. 

There  are  three  modes,  in  some  or  all  of  which  these  affections 
manifest  themselves — namely,  by  causing  disturbance  of  function, 
alteration  of  sensibility,  or  change  of  texture. 

The  ovaries  are  the  grand  organs  of  sexual  activity  in  the  female ; 
and  during  the  whole  time  that  sexual  life  continues,  they  are 
employed  in  the  healthy  individual  in  bringing  ova  to  maturity, 
and  then  in  extruding  them  at  certain  periods  when  they  have 
attained  a  state  of  fitness  for  further  develo[iment,  if  subjected  to 
the  fecundating  influence  of  the  semen.  Accompanying  this  in- 
ternal process,  the  consequence  and  the  evidence  of  the  local  con- 
gestion which  attends  it,  we  observe  a  periodical  discharge  of  blood 
constituting  menstruation.     The  regular  return  of  menstruation, 


SIGNS    OF    SEXUAL    DISORDER.  21 

its  accomplishment  within  a  given  period,  attended  by  a  certain 
average  amount  of  discharge,  and  by  no  more  than  a  certain  average 
degree  of  discomfort,  are  regarded  by  women,  and  with  propriety, 
as  "conclusive  evidences  of  the  healthy  state  of  the  sexual  functions. 
In  every  inquiry  therefore,  with  regard  to  supposed  disease  of  the 
generative  apparatus,  the  mode  in  which  this  function  is  performed 
must  engage  your  careful  attention.  You  know  menstruation  to 
be  merely  the  sign  of  a  more  important  process  going  on  deeper 
within  the  organism.  The  non-appearance  of  the  discharge,  then, 
or  its  suppression,  suggests  at  once  many  important  inquiries  which 
must  be  carefully  followed  up,  till  you  can  return  to  them  a  satis- 
factory reply.  Is  the  system  so  feeble  that,  like  an  ill-thriven 
plant,  its  sexual  power  remains  altogether  in  abeyance  ?  or  are 
the  ovaries  themselves  diseased  ?  or  does  the  internal  process  go 
on,  while  yet,  owing  to  some  mechanical  cause  obstructing  the 
escape  of  the  discharge,  its  outward  manifestation  is  wanting?  or 
is  its  appearance  prevented  by  some  disorder  of  the  general  system, 
or  of  the  uterus,  which  incapacitates  that  organ  from  performing 
its  usual  office  as  a  kind  of  safety-valve  by  means  of  which  the 
congested  pelvic  vessels  are  relieved  of  their  superabundant  blood? 
Or  is  perchance  none  of  these  suppositions  correct,  and  is  the  real 
explanation  of  the  suppression  of  the  menses  to  be  found  in  a 
physiological  not  in  a  pathological  occurrence,  and  are  the  symp- 
toms those  of  pregnancy,  not  those  of  disease  ?  Such  are  the 
important  questions  which,  in  every  case  of  suppressed  menstrual 
discharge,  you  must  endeavor  to  answer,  and  to  which,  both  for 
your  own  reputation  as  well  as  for  your  patient's  well-being,  it  is 
of  the  greatest  moment  that  you  should  return  a  correct  reply. 
Or,  again,  your  patient  sutlers  from  what  she  conceives  to  be  ex- 
cessive menstruation,  her  health  is  breaking  down  beneath  it. 
Whence  comes  the  discharge  ?  is  it  due  to  a  state  of  general  pleth- 
ora, which  nature  endeavors  to  relieve  by  this  outlet,  though 
in  her  endeavors  she  exceeds  the  limits  of  safety?  or  are  the  vessels 
so  weak  that  blood  escapes  from  them  with  dangerous  profusion  ? 
or  is  the  hemorrhage  due  to  neither  of  these  causes,  but  to  a  breach 
of  surface,  to  some  ulcer  of  the  womb  from  which  the  blood  flows, 
or  to  some  morbid  growth,  or  formidable  organic  disease,  the  effect 
of  which  is  rendered  more  serious  just  at  those  times  when  the 
uterus  becomes  more  than  usually  congested  ?  These,  and  similar 
inquiries,  possess  a  special  importance  at  certain  epochs  of  a 
woman's  life ;  for  wlion  the  sexual  powers  are  on  the  decline, 
disease  is  especially  liable  to  be  set  up,  and  you  therefore  regard 
all  menstrual  irregularities  at  that  time  with  closer  attention  than 
at  any  former  period. 

But  there  are  other  subsidiary  functions  perfomtied  by  the  gener- 
ative organs,  the  disturbance  of  which  is  sometimes  the  occasion 
of  mere  discomfort,  at  other  times  the  indication  of  serious  disease. 
These  organs  present  a  great  variety  of  secreting  surtaces,  which 
furnish  matters  of  various  kinds,  subserving  various  purposes.  A 
slight  secretion  moistens  the  interior  of  the  Fallopian  tubes,  just 


22  SIGNS    OF    SEXUAL    DISORDER. 

as  it  does  that  of  all  viscera,  and  except  near  the  monthly  periods 
of  sexual  activity,  it  is  by  little  more  than  a  mere  halitus  that  the 
cavity  of  the  womb  itself  is  lubricated.  The  large  mucous  crypts 
or  glands  about  its  neck  furnish  a  peculiar  secretion,  which  is 
generally  present  at  all  times,  though  most  abundant  during  preg- 
nancy. The  mucous  follicles  of  the  vagina  pour  out  a  somewhat 
copious  secretion  upon  its  surface  ;  and  the  two  glands  which  are 
seated  one  on  either  side  of  its  entrance,  and  w^hich,  under  the 
name  of  Duverney's  glands,  correspond  to  Cowper's  glands  in  th« 
male,  furnish  an  abundant  discharge  at  the  time  of  sexual  con- 
gress ;  and,  lastly,  numerous  mucous  crypts  and  sebaceous  follicles 
on  the  nymphae,  the  interior  of  the  labia,  and  about  the  vestibulum, 
supply  a  suitable  secretion  to  lubricate  those  parts.  From  any 
or  all  of  these  sources  secretion  may  be  furnished,  excessive  in 
quantity,  and  more  or  less  altered  in  character.  The  secretion  may 
be  a  mere  leucorrhoea,  an  increased  flux  from  otherwise  healthy 
tissue  ;  it  may  be  a  purulent  discharge  from  inflammation  of  a 
mucous  membrane,  or  it  may  be  furnished  from  an  ulcer  of  the 
womb ;  or,  it  may  not  be  simple  pus,  but  an  offensive  sanies  from 
a  wide-spread  cancer  of  the  organ,  or  of  some  part  adjacent.  Your 
patient  may  come  to  you  in  complete  ignorance  as  to  which  of  all 
these  is  the  cause  of  the  affection  under  which  she  is  laboring : 
she  looks  to  you  for  an  answer  to  her  doubts,  and  for  relief  to  her 
sufferings. 

Diseases  of  these  organs,  however,  are  associated  not  merely  with 
altered  function,  but  also  with  disordered  sensibility,  and  that  not 
only  of  the  part  affected,  but  also  of  others  more  or  less  distant. 
There  is  hardly  any  more  fertile  source  of  erroneous  diagnosis  with 
reference  to  the  diseases  of  women  than  the  overlooking  the  import 
of  some  of  these  alterations  of  sensibility,  and  the  not  connecting 
with  its  proper  cause  the  sympathetic  affection  of  some,  perhaps, 
distant  organ.  If  a  woman  complain  of  a  sense  of  heaviness  in 
the  pelvis,  of  bearing-down  pain,  of  pain  in  the  loins  and  about 
the  sacrum,  or  shooting  down  the  thighs,  our  attention  is  naturally 
directed  to  the  state  of  her  sexual  organs,  and  we  are  not  likely, 
with  moderate  caution,  to  overlook  the  real  seat  of  her  disease. 
In  many  cases  too,  something  beyond  the  seat  of  the  disease  may 
be  learned  if  we  notice  the  character  of  the  pain  from  which  the 
patient  suffers,  since  this  is  usually  of  one  kind  if  inflammation  be 
present,  of  another  if  there  be  cancerous  disease,  of  a  third  if  there 
be  displacement  of  the  womb.  These  minutise,  too,  are  of  all  the 
more  importance  for  us  to  attend  to,  since  there  are  no  other  dis- 
eases in  which  that  personal  investigation  by  which  so  many 
questions  can  be  at  once  answered  is  attended  by  so  many  diffi- 
culties, both  from  the  natural  repugnance  of  the  patient  to  submit 
to  it,  as  well  as  from  the  imperfection  of  our  means  of  examina- 
tion. 

But  disease  of  these  organs  is  not  seldom  attended  by  pain  which 
is  referred  not  to  the  real  seat  of  the  mischief,  but  to  some  other, 
perhaps  some  distant  part.     Women  may  apply  to  you  who  seem 


ALTERED     SENSIBILITY.  23 

out  of  "health,  and  in  whom  you  may,  perhaps,  at  first,  suspect  the 
existence  of  uterine  disease;  but  they  appear  annoyed  at  inquiries 
with  reference  to  their  sexual  functions,  or  perhaps  deny,  and  with 
perfect  truth,  the  existence  of  any  pain  in  the  uterus,  or  its  imme- 
diate neighborhood.  Perhaps,  however,  they  may  confess  to  pain 
in  the  rectum,  especially  at  the  time  of  defecation  ;  or  may  speak 
of  symptoms  which  they  refer  to  hemorrhoids  ;  or  may  complain 
of  sciatica,  or  of  lumbago.  Always  suspect  the  import  of  these 
sufferings ;  bear  in  mind  the  wide  sympathies  of  the  pregnant 
womb,  and  keep  all  your  vigilance  active  ;  it  is  highly  probable 
that  these  anomalous  symptoms  will  resolve  themselves  into  the 
effects  of  uterine  disease. 

Nor  are  they  merely  strange  and  intractable  forms  of  local  ail- 
ment which  should  call  your  special  attention  to  the  uterus  and  its 
functions.  The  pregnant  woman  suffers  almost  invariably  from 
nausea  and* vomiting;  her  appetite  often  becomes  capricious,  and 
her  digestive  functions  are  frequently  ill  performed ;  while  it  is  far 
from  unusual  for  her  to  have  attacks  of  headache,  or  of  tic-doalou- 
reux,  though  she  may  at  other  times  enjoy  a  complete  immunity 
from  all  such  ailments.  But  just  as  disorder  of  the  functions  of 
other  organs  not  seldom  attends  upon  the  physiological  processes 
going  on  in  the  womb,  so  may  it  follow  upon  uterine  irritation 
produced  by  disease ;  and  a  large  proportion  of  the  most  obstinate 
forms  of  dyspepsia,  and  a  still  larger  number  of  hysterical  and 
nervous  afi'ections,  have  been  excited  and  are  kept  up  by  disease 
of  the  womb.  In  a  great  many  of  these  cases,  minute  inquiry 
elicits  evidence  of  functional  disorder  of  the  generative  organs,  as 
shown  by  disturbed  menstruation,  by  leucorrhocal  discharges,  or 
by  painful  sensations,  although  noiie  of  these  symptoms  may  have 
been  so  marked  as  to  have  engaged  the  patient's  notice ;  or  she 
may  have  regarded  them  as  trivial  accidents  not  worth  mention 
when  compared  with  the' other,  and  to  her  feelings  the  more  im- 
portant causes  of  her  sufferings.^ 

Need  I  guard  myself  against  being  misunderstood — against  be- 
ing supposed  to  say  that,  in  the  management  of  a  woman  who  is 
d^'speptic,  your  attention  is  to  be  turned  less  to  the  state  of  her 
stomach  than  to  that  of  her  womb ;  or  that,  if  a  woman  suffer 
from  neuralgia,  you  are  at  once  to  suspect  the  existence  of  uterine 
disease?  I  mean  no  such  thing;  but  what  I  do  mean  is,  that,  in 
the  treatment  of  diseases  occurring  among  patients  of  the  female 
sex,  you  should  always  bear  in  mind  tliat,  besides  the  ordinary 
causes  of  disease  common  to  both  sexes,  there  is  another  set  of 
causes  peculiar  to  themselves.  Whenever,  therefore,  the  ordinary 
principles  of  pathology  fail  to  explain,  or  the  ordinary  proceedings 
of  therapeutics  prove  inadequate  to  cure  the  ailments  of  any  female 

1  In  vol.  ii  of  Lisfranc's  Cliniqiie  Chirurgicalc,  8vo.,  Paris.  1842,  from  p.  182  to 
p.  256,  are  some  remarks,  with  illustrative  cases,  on  errors  of  diai^nosis  in  uterine 
disease,  which,  though  not  free  from  the  characteristic  faults  of  that  writer,  will 
yet  well  repay  an  attentive  perusal. 


24  EXAMINATION  OF  THE  ABDOMEN. 

patient,  it  behooves  you  to  remember  that  in  her  sex,  and  in  its 
peculiar  diseases,  you  may  perhaps  find  a  ckie  to  the  cause  of  her 
present  symptoms,  and  discover  indications  which  may  show  you 
bow  to  accomplish  their  cure. 


LECTURE    II. 

INTEODUCTOKY. 


Symptoms  of  diseaise  of  generative  organs,  furnished  by  alterations  of  size,  texture, 
or  situation,  to  be  ascertained  only  by  examination — General  remarks  on  the 
subject — Examination  either  tactile  or  instrumental — Tactile  examination  of 
the  abdomen,  per  vaginam,  jier  rectum — Instrumental  examination,  by  means 
of  the  Uterine  Sound ;  descri])tion  of  the  instrument,  and  rules  for  its  intro- 
duction;  examination  with  the  Speculum  ;  varieties  of  the  instrument;  rules 
for  its  introduction  ;  attempt  to  estimate  its  value. 

There  was  not  time  at  our  last  meeting  for  the  due  considera- 
tion of  the  tldrd  and  last  class  of  indications  of  disease  of  the  genera- 
tive organs — namely,  those  furnished  bi/  alterations  of  their  size,  tex- 
ture, or  situation.  I  must  therefore  direct  your  attention  to  them 
to-day. 

It  is,  I  conceive,  quite  needless  for  me  to  preface  what  I  have  to 
say  by  any  remarks  upon  the  importance  of  these  signs,  or  upon 
the  necessity  of  ascertaining  the  presence  or  absence  of  any  of 
these  changes  in  a  great  majority  of  the  cases  in  which  our  pa- 
tient's symptoms  indicate  some  disorder  of  her  sexual  functions. 

The  examination,  however,  by  which  alone  this  information  can 
be  obtained,  must  be  extremely  painful  to  a  woman's  feelings, 
since  she  is  not  now,  as  in  the  time  of  labor,  impelled  by  the 
extremity  of  her  sufterings  to  submit  to  anytliing  for  the  sake  of 
relief.  She  seems,  indeed,  to  be  now  peculiarly  alive  to  every 
painful  impression ;  and  while  she  feels  almost  overwhelmed  by  a 
sense  of  humiliation  at  having  to  undergo  an  examination,  of  the 
necessity  for  which  she  may  yet  feel  fully  convinced,  she  will 
judge  with  painful  minuteness  each  act  of  yours — any  needless 
delay,  any  careless  exposure  of  her  person,  any  apparent  want  of 
delicacy  or  consideration.  With  the  greatest  care,  indeed,  you 
will  not  always  escape  from  undeserved  blame ;  without  it,  you 
will  perpetually  wound  your  patient's  feelings,  and  if  you  do  not 
injure  your  own  prospects,  you  will  yet  fail  to  support  the  dignity 
of  your  profession,  and  will  lead  to  the  inference  that  there  is  at 
least  one  department  of  the  art  of  healing  incompatible  with  the 
tone,  and  manner,  and  feeling  of  a  high  bred  gentleman.  The 
familiarity  which  hospital  practice  begets  with  these  ailments 
among  women  whose  sensibilities  are  not  always  as  keen  as  those 
of  persons  in  a  higher  class  of  life,  or  the  circumstance  that  they 
do  not  venture  to  express  the  pain  which  want  of  consideration 


EXAMINATION    OF    THE    ABDOMEN.  25 

may  have  caused  them,  leads  but  too  often  to  carelessness  in  these 
respects  on  the  part  of  men  who  would  yet  shrink  from  the  idea 
of  inflicting  a  moment's  unnecessary  sutfering  upon  any  one.  I 
am  therefore  all  the  more  anxious  to  impress  upon  you  that  the 
delicacy  with  which  you  ought  to  conduct  all  your  investigations 
into  the  diseases  of  women,  is  not  a  thing  which  can  be  assumed 
for  the  nonce,  but  that  it  must  be  the  habit  of  the  mind,  must 
therefore  have  been  acquired  now  during  your  pupilage,  and  in 
the  midst  of  your  intercourse  with  the  poor. 

We  make  ourselves  acquainted  with  the  existence  of  disease  of 
the  generative  organs,  either  by  manual  examination  or  by  ocular 
inspection ;  and  for  the  purpose  of  making  such  investigations  with 
the  greater  accuracy,  we  not  infrequently  employ  instruments  of 
different  kinds.  The  simplest  mode  of  examination,  and  that  which 
causes  our  patient  the  least  distress  or  alarm,  is  that  in  which  we 
employ  our  sense  of  touch  alone,  unaided  by  any  apparatus  what- 
ever. It  is  perhaps  scarcely  necessary  for  me  to  remind  you  that, 
while  it  is  our  duty  to  use  every  means  essential  to  the  thorough 
investigation  of  our  patient's  condition,  it  is  no  less  our  duty  to 
make  no  needless  examination  ;  never  to  use  an  instrument  when 
we  can  ascertain  all  that  is  necessary  without  it ;  never  to  resort 
to  ocular  inspection  when  we  can  feel  a  reasonable  certainty  that 
by  the  sense  of  touch  alone  we  have  arrived  at  a  true  knowledge 
of  the  disease. 

We  derive  information  from  our  sense  of  touch  when  applied 
either  through  the  abdominal  walls,  or  by  the  vagina,  or  the  rec- 
tum. Examination  of  the  abdomen  is  not  always  called  for;  when 
it  appears  necessary,  it  is  well  to  begin  with  it.  For  this  purpose 
the  patient  should  lie  upon  her  back,  with  her  knees  drawn  up  so 
as  to  relax  the  abdominal  muscles.  It  is  very  seldom  necessary 
to  apply  the  hand  to  the  uncovered  surface ;  the  interposition  of 
the  patient's  shift  little  if  at  all  interfering  with  the  accuracy  of 
the  examination.  Care  should  be  taken  that  your  hands  are  not 
cold ;  if  they  are,  this  will  not  only  annoy  your  patient,  but,  by 
exciting  contraction  of  her  al)dominal  muscles,  may  seriously  im- 
pede your  investigation.  Placing  both  hands  upon  the  abdomen, 
you  make  at  first  very  gentle  pressure,  increasing  it  by  degrees  as 
the  patient  becomes  accustomed  to  it,  and  trying  to  engage  her  in 
conversation,  and  thus  to  distract  her  attention,  if  either  pain  or 
alarm  should  cause  her  to  throw  her  abdominal  muscles  into 
action.  You  thus  make  yourself  acquainted  with  the  general  con- 
tour of  the  abdomen,  and  by  examining  at  either  side  as  well  as 
in  the  centre,  you  detect  any  tumor  which  may  be  present  there. 
Su]iposing  any  such  growth  to  be  discovered,  you  must  examine 
well  its  form,  its  size,  its  attachments,  its  degree  of  mobility,  and 
the  amount  of  tendersess  or  pain  which  meddling  with  it  occa- 
sions. Is  it  due  to  accunmlation  of  fjeces  in  the  large  intestine; 
to  enlargement  of  the  liver  or  spleen  ;  or  is  it  pcrha}»s  merely  the 
result  of  a  general  fulness  of  the  abdomen  produced  by  flatus  in 
the  bowels,  or  by  fat  in  the  omentum  or  beneath  the  integuments, 


26  SIGNS    OF    SEXUAL    DISORDER. 

rather  tlian  the  consequence  of  any  definite  disease  ?  If  the 
tumor  seem  to  arise  from  out  of  the  pelvis,  it  is  most  probably 
formed  either  by  the  uterus  itself,  or  by  its  appendages.  If  by 
the  former,  the  chances  are  that  it  will  be  situated  in  the  mesial 
line  of  the  abdomen ;  if  by  the  latter,  that  it  will  occupy  one  or 
other  side,  or  at  any  rate  that  it  will  be  learned  to  have  occupied 
that  situation  when  first  discovered.  "Whether  it  is  solid  or  fluc- 
tuating, even  or  irregular,  will  be  other  points  for  you  now  to  make 
out,  and  you  must  then  proceed  to  correct  or  confirm,  by  a  vaginal 
examination,  the  impressions  received  on  examining  through  the 
abdominal  walls. 

It  is  seldom  necessary,  for  the  purposes  of  a  vaginal  exavnna- 
tion,  that  the  patient  should  be  in  any  other  than  the  usual  ob- 
stetric position.  On  the  Continent,  where  women  are  generally 
delivered  on  the  back,  they  often  assume  that  position  whenever 
the  state  of  the  uterus  needs  investigation.  Sometimes,  too,  when 
it  is  wished  to  appreciate  the  degree  of  prolapse  or  downward  dis- 
placement of  the  uterus,  or  to  estimate  its  increase  in  weight,  or 
when  the  womb  is  high  up  and  does  not  come  readily  within 
reach,  the  examination  is  made  with  the  patient  in  the  standing 
position  ;  I  do  not  think,  however,  that  any  of  the  alleged  advan- 
tages of  this  attitude  are  sufiicient  to  counterbalance  its  very  ob- 
vious inconveniences.  The  patient,  therefore,  lying  on  her  left 
side,  the  index  finger  of  the  right  hand  is  introduced  as  for  an 
examination  in  labor,  and  as  it  is  slowly  carried  forward,  atten- 
tion is  to  be  paid  to  the  degree  of  pain  excited  in  each  part  of  its 
course.  Tlic  state  of  the  external  organs  must  be  noticed,  and 
then  that  of  tlie  vagina — whether  it  is  hot  and  swollen,  or  cool 
and  relaxed ;  whether  dry,  or  abundantly  bathed  in  secretion. 
The  cervix  uteri  is  thus  reached,  and  you  observe  whether  or  no 
it  is  tender,  what  are  its  length,  and  size,  and  texture ;  whether 
the  OS  uteri  is  open  or  closed;  whether  its  lips  are  small  and  even, 
or  rough  and  irregular.  You  will  bear  in  mind,  that  after  fre- 
quent  childbearing,  the  cervix  uteri  is  both  shorter  and  broader 
than  in  the  woman  who  has  never  given  birth  to  children  (changes 
which  are  especially  marked  in  that  portion  of  it  which  projects 
into  the  vagina,  and  is  commonly  called  the  portio  vaginalis) ;  and 
that  the  os  uteri  is  frequently  open,  so  as  to  admit  the  finger  with 
but  little  difficulty.  In  this  case,  however,  the  inner  surface  of 
the  OS  is  smooth,  and  the  tissue  of  the  cervix  soft  and  yielding ; 
while  if  disease  exist,  the  interior  of  the  os  will  most  likely  be 
rough  and  uneven,  and  the  substance  of  the  cervix  rigid.  Some- 
times a  peculiar  and  almost  velvety  smoothness  is  presented  by 
the  surface  of  the  os  uteri,  or  the  tissue  generally  has  less  than  its 
natural  firmness  ;  and  any  of  these  peculiarities,  or  the  presence 
of  any  foreign  body  between  the  lips  of  the-  uterus,  should  be  well 
borne  in  mind,  in  order  that  you  may  afterwards  compare  the  in- 
formation obtained  by  ocular  inspection  with  that  previously 
gained  by  the  sense  of  touch.  While  making  this  examination, 
you  notice,  moreover,  the  situation  of  the  uterus,  whether  it  still 


EXAMINATION  BY  VAGINA  AND  RECTUM.        27 

retains  its  natural  direction,  or  has  come  to  lie  with  its  axis  cor- 
responding to  the  axis  of  the  vagina;  whether  it  is  bent  upon 
itself,  or  in  any  other  way  misplaced.  Examine  next  whether  the 
uterus  is  increased  in  weight ;  balance  it  on  your  finger,  and  ap- 
preciate as  well  as  you  can  the  size  and  weight  of  the  organ.  If 
you  had  discovered  any  tumor  by  examination  through  the  ab- 
dominal walls,  you  should  now  try  to  ascertain  whether  there  is 
any  connection  between  it  and  the  uterus,  or  between  it  and  any 
other  tumor  that  you  may  detect  within  the  pelvis,  and  whether 
pressure  on  the  one  in  any  way  modifies  the  position  of  the  other. 
For  this  purpose,  too,  it  is  advisable  to  let  the  patient  lie  on  her 
back,  when,  with  one  hand  placed  over  the  pubes,  and  the  finger 
of  the  other  in  the  vagina,  the  size  of  the  womb  and  the  relations 
borne  to  it  by  any  tumor  can  be  made  out  far  more  accurately 
than  is  possible  while  the  position  on  the  side  is  maintained. 
When  all  the  above-mentioned  points  have  been  ascertained,  with 
as  much  gentleness  as  possible,  the  vaginal  examination  is  over, 
and  there  is  nothing  more  for  you  to  notice,  except  it  be  the  ap- 
pearance or  other  characters  of  the  discharge. 

Sometimes  it  is  expedient  to  examine  per  rectum  as  well  as  per 
vaginam ;  if  either  the  patient  had  made  complaints  of  serious 
pain  in  the  bowel,  or  if  you  had  discovered  a  tumor  situated  be- 
hind or  to  one  side  of  the  uterus,  or  if  on  any  account  you  are 
anxious  to  examine  the  posterior  part  of  the  pelvis,  or  of  the  uterus 
itself,  as  completely  as  possible.  The  only  caution  specially  ap- 
plicable to  examination  per  rectum  is,  that  owing  to  the  interven- 
tion of  the  intestine  between  the  finger  and  the  womb,  that  organ 
feels  much  larger  than  it  really  is ;  besides  which,  as  the  finger 
reaches  less  readily  to  a  level  with  the  cervix  uteri  when  intro- 
duced into  the  rectum  than  into  the  vagina,  there  is  some  risk  of 
mistaking  the  cervix  for  a  prominence  of  the  posterior  wall  of  the 
uterus,  or  for  a  tumor  in  that  situation,  or  for  a  retroversion  or 
retroflcction  of  the  organ,  when,  in  reality,  no  morbid  condition 
whatever  is  present. 

Of  late  years  it  has  become  customary  in  many  cases  to  aim  at 
a  greater  completeness  of  tactile  examination,  by  means  of  an  in- 
strument which  is  called  the  Uterine  Sound.  At  different  times, 
indeed,  practitioners  have  in  some  special  instance  introduced  a 
catlieter  into  the  uterus  to  satisfy  themselves  of  the  size  of  its 
cavity,  or  of  the  absence  of  any  foreign  body  from  its  interior;  or 
have  attempted  to  rectify  a  retroversion  of  the  unimpregnated 
womb,  by  means  of  an  instrument  introduced  within  it.'  To 'the 
best  of  my  knowledge,  however,  a  Frenchman,  M.  Lair,  ^vas  the 
first  person  who,  between  thirty  and  forty  years  ago,  recommended 

'  Tlic  late  Professor  Osiander,  of  Gottiiiijjcn,  employed  his  Dilatoriiim  Orificii 
Uteri,  which  is  described  in  llDsenmcyer's  dissertation,  jnil)lished  at  Gottini^en  in 
1802,  on  three  occasions,  to  reduce  the  retroverted  unini))r('i:;nated  womb.  His 
cases  were  published  in  the  Medlc'misch  Chlnirgische  Zrifuni/  for  1808,  according  to 
Schmitt,  who  refers  to  them  in  his  Essay,  Ueber  die  Zuruckbeuguny  der  Qebiirmutter, 
Svo.,  Wien,  1820. 


28  SIGNS    OP    SEXUAL    DISORDER. 

Bounding  the  interior  of  the  uterus  in  order  to  ascertain  whether 
the  cervix  is  free  from  all  impediments,  and  whether  the  cavity  of 
the  orfi^an  generally  is  in  healthy  state.  His  book  is  illustrated 
with  drawings  of  the  instruments  which  he  employed  for  this 
purpose  ;'  and  he  advised  that  the}^  should  be  curved  like  a  catheter 
at  their  uterine  extremity,  in  order  to  facilitate  their  introduction. 
He  recommends,  moreover,  that  the  sound  should  be  introduced 
through  a  metallic  cylinder  or  speculum,  by  which  the  mouth  of 
the  womb  is  to  be  first  brought  into  view  ;  a  proceeding  which, 
instead  of  facilitating  the  introduction  of  the  instrument,  must,  in 
many  cases,  have  rendered  it  altogether  impossible.  The  practi- 
cal defects  of  M.  Lair's  plans  prevented  their  general  adoption  ; 
and  his  recommendations  were  in  consequence  soon  forgotten. 
To  Dr.  Simpson,^  of  Edinburgh,  belongs  the  merit,  not  only  of 
having  recalled  attention  to  the  subject,  but  of  having  also  in- 
vented a  Uterine  Sound,  admirably  adapted  for  the  safe  and  easy 
exploration  of  the  cavity  of  the  womb.  His  instrument  is  made 
of  flexible  metal ;  and  in  shape  and  size  closely  resembles  a  sound 
for  the  male  bladder,  having  a  similar  curve,  and  its  handle  being 
flat,  and  roughened  on  one  side  in  the  same  manner.  The  uterine 
end  of  the  instrument  terminates  in  a  small  bulb,  to  prevent  its 
injuring  the  interior  of  the  womb,  while  a  notch  at  every  inch 
serves  to  indicate  the  distance  to  which  the  sound  has  entered 
the  womb,  and  tlius  to  mark  the  size  of  its  cavity.  A  slight  prom- 
inence at  two  and  a  half  inches  shows  the  average  length  of  the 
cavitji  of  the  healthy  womb,  while  a  deep  depression  at  four  and  a 
half  inches  marks  a  size,  which,  except  under  very  special  circum- 
Btances,  the  organ  hardly  ever  exceeds.^ 

The  mode  of  using  the  instrument  is  sufiiciently  simple.  Two 
fingers  of  the  left  hand  are  introduced  behind  the  cervix  uteri,  as 
the  patient  lies  on  her  back  or  on  her  left  side,  and  the  sound  is 
slid  along  the  fingers  till  its  point  reaches  the  os  uteri,  when,  by 
depressing  the  handle  towards  the  perineum,  and  at  the  same  time 
carrying  the  instrument  gently  forwards,  it  will  enter  the  uterine 
cavity.  I  need  not  say,  that  it  must  never  be  employed  when  the 
least  ground  exists  for  suspecting  pregnancy;  and  that  in  no  cir- 
cumstances must  force  be  used  in  its  introduction.  In  the  majority 
of  cases  the  introduction  of  the  sound  causes  some  pain,  tliough 
this  is  generally  by  no  means  severe,  and  is  almost  always  of  veiy 

1  Nouvelle  Methode  du  Traitement  des  Ulrh-es,  etc.,  de  V  Uterus,  8vo.,  Paris,  1828. 
Deuxi^me  Edition,  p.  137.     The  first  edition  apjDeared  about  two  years  before. 

*  In  a  series  of  papers  in  Londun  and  EdinbicrgJi  Monthly  Journal  for  1843. 

3  Many  modifications  of  the  Uterine  Sound  have  been  suggested  bj'^  Valleix, 
Kiwisch,  Huguier,  and  still  more  recently  by  Dr.  Kugelmann,  of  Hanover.  {Ver- 
handl.  d.  Gesellschaft  f.  Gebnrtshulje,  Nov.  1861,  Zeitschr.  f.  Gehurtsk,  vol.  xix,  p. 
120).  This  last  is  very  ingeniously  contrived  with  a  movable  scale  which  slides 
on  the  sound  itself,  and  indicates  at  the  handle  the  distance  to  which  the  instru- 
ment has  entered  the  uterus,  so  that  the  prominence  and  the  notches  that  interfere 
with  the  introduction  of  Simpson's  sound,  are  done  away  with.  The  difficulties  in 
the  employment  of  the  original  instrument  are,  however,  so  slight,  and  simplicity 
is  of  such  great  value,  that  I  still  prefer  Simpson's  sound  to  anj' of  the  other  varie- 
ties of  the  instrument. 


EMPLOYMENT    OF    THE    SPECULUM.  29 

short  duration;  and  in  no  instance  which  has  come  under  my 
observation,  have  dangerous  consequences  resulted  from  its  use, 
tliough  awkwardness  and  foolhardiness  have,  I  know,  done  mis- 
chief with  this,  as  with  almost  all  instruments  that  have  ever  been 
invented. 

The  information  which  this  instrument  places  within  our  reach 
is  often  extremely  valuable ;  and  of  a  kind  such  as  otherwise  we 
could  not  obtain  at  all,  or  could  arrive  at  only  very  slowly,  and  by 
frequently  repeated  examinations.  If,  in  a  patient  suffering  from 
frequent  hemorrhages,  we  ascertain  the  uterine  cavity  to  be  greatly 
increased  in  size,  our  immediate  conclusion  is  that  the  womb  con- 
tains some  foreign  body,  as  a  polypus  or  fibrous  tumor,  the  pres- 
ence of  which  has  excited  and  serves  to  keep  up  the  bleeding.  If 
we  doubt  whether  a  tumor  proceeds  from  tlie  womb,  or  from  its 
appendages,  or  from  some  other  part  within  the  pelvis,  the  sound 
enables  us  to  estimate  the  weight  of  the  organ,  and  to  strengthen 
the  inference  drawn  from  this  experiment,  by  completely  isolating 
the  womb  from  the  tumor,  and  thus  ascertaining  positively  their 
independence  of  each  other.  Or  lastly,  if  the  uterus  is  bent  upon 
itself  either  forwards  or  backwards,  the  diagnosis  of  this  condition, 
which  once  was  a  matter  of  much  difficulty,  is  now  often  arrived 
at  with  facility,  by  introducing  the  sound  with  its  concavity  di- 
rected towards  the  swelling  we  detect  per  vaginam,  and  observing 
whether  or  no  this  swelling  disappears  on  turning  round  the  in- 
strument. I  will  not  now  go  into  further  detail  on  the  subject, 
for  I  shall  hereafter  have  to  refer  on  many  occasions  to  this  valu- 
able aid  to  diagnosis.  The  uterine  sound,  indeed,  is  not  always 
applicable  ;  nor  does  it,  when  used,  always  clear  up  our  doubts ; 
but  I  do  not  remember  any  instance  in  which  a  diagnosis  based 
on  the  information  which  it  afforded  turned  out  afterwards  to  be 
erroneous. 

The  idea  of  adopting  some  contrivance  by  which  the  condition 
of  the  uterus  might  be  examined  by  the  eye  was  not  altogether 
unknown  to  the  ancients,  though  for  the  most  part  those  instru- 
ments, of  which  drawings  may  be  seen  in  old  works  on  midwifery, 
and  which  received  the  name  of  Speculum  Matricis^  were  used  for 
dilating  the  mouth  of  the  womb  during  labor,  rather  than  for 
examining  its  condition  in  disease.^  An  instrument  similar  in 
kind,  however,  appears  to  have  been  sometimes  employed  for  the 
investigation  of  disease  of  the  uterus  and  vagina,  though  it  never 
came  into  anything  like  general  use.  The  introduction  of  the 
speculum  into  modern  practice  as  a  means  of  facilitating  the  inves- 
tigation of  uterine  disease  does  not  date  further  back  than  the  year 
1821,  when  the  instrument  was  first  employed  by  M.  Rccamier. 
This,  which  was  merely  a  C3'linder,  conical  in  form,  rounded  off  a 
little  at  its  uterine  extremity,  and  bevelled  at  its  otlu-r  end,  was 
next  fitted  with  a  small  handle  by  M.  Dupuytren,  and  afterwards 

1  Soe  some  remarks  and  quotations  referring  to  the  early  history  of  the  speculum, 
in  Balbirnie,  Oryanic  Diseases  of  the  Womb^  pp.  41-45,  8vo.,  London,  183G. 


30  EULESFORTHE 

a  plug  was  adapted  to  it  to  render  its  introduction  more  easy. 
Various  materials  have  been  used  in  the  fabrication  of  these  in- 
struments, but  we  owe  the  greatest  improvement  in  this  respect 
to  Mr.  Fergusson  of  King's  College.  Instead  of  employing  metal, 
which  is  very  apt  to  tarnish,  and  never  has  a  very  powerful  re- 
flecting surface,  or  glass,  which  though  very  useful  when  caustics 
are  to  be  applied  to  the  uterus  or  vagina,  since  they  do  not  act 
upon  it,  is  yet  liable  to  be  broken,  and  moreover,  owing  to  its 
transparency,  does  not  reflect  very  powerfully,  he  adopts  the  fol- 
lowing plan :  A  glass  speculum  is  silvered  on  its  outside,  by 
which  means  the  inner  surface  is  converted  into  a  mirror  easily 
kept  clean,  and  on  which  no  caustics  can  act.  The  speculum  is 
then  enveloped  in  successive  layers  of  cotton-cloth,  each  of  which 
is  covered  with  a  solution  of  Indian-rubber,  and  when  the  glass 
has  thus  received  a  coating  of  sufiicient  thickness  it  is  varnished, 
and  forms  an  instrument  which  is  now  in  general  use.  Its  funnel- 
shaped  termination  is  intended  to  provide  for  the  admission  of  as 
much  light  as  possible ;  a  point  of  the  more  importance  in  this 
country,  from  the  almost  universal  practice  of  examining  patients 
on  their  side,  in  which  posture  light  has  a  less  ready  accesS  to  the 
parts  than  if,  as  on  the  Continent,  the  patient  lay  on  her  back. 
The  object  of  the  instrument  being  slightly  bevelled  oft'  at  its 
uterine  extremity,  is  that  the  same  advantage  is  thereby  secured^ 
as  if  the  diameter  of  the  cylinder  throughout  were  greater.  This 
sloping  oft"  of  the  instrument,  however,  must  not  be  carried,  as 
some  have  recommended,  so  far  as  to  amount  to  an  angle  of  forty- 
five  degrees,  since  by  so  doing  the  inconvenience  is  encountered 
of  a  fold  of  vagina  falling  down  in  front  of  the  cervix  uteri.  The 
specula  which  I  use  may  perhaps  appear  to  you  of  an  unnecessary 
length;  but  you  must  bear  in  mind  that  the  vagina  is  very  exten- 
sile, and  that  when  a  speculum  is  introduced  into  it,  the  canal  is 
stretched  in  length  as  well  as  in  width,  so  that  the  ordinary  length 
of  the  vagina  is  not  to  be  taken  as  the  measure  for  the  length  of 
the  speculum.  I  believe  the  attempt  to  reach  the  os  uteri  fails 
from  the  shortness  of  the  speculum  oftener  than  from  almost  any 
cause,  and  quite  agree  with  the  opinion  of  the  late  Professor  Lis- 
franc  of  Paris,^  that  a  speculum  ought  to  be  seven  inches  long. 

In  spite  of  the  general  convenience  of  the  cylindrical  speculum, 
however,  there  are  some  drawbacks  from  its  utility.  Owing  to  the 
entrance  of  the  vagina  being  narrower  than  any  part  of  its  canal, 
it  happens  sometimes  that  a  speculum  sutficiently  small  to  pass 
without  causing  the  patient  severe  pain,  is  not  large  enough  to 
bring  the  whole  of  the  os  uteri  into  view.  But  even  though  its 
whole  surface  be  exposed,  yet  the  cylindrical  speculum  pressing 
the  lips  of  the  os  together  may  prevent  a  good  view  being  obtained 
of  its  interior,  and  may  thus  render  the  examination  incomplete 

1  This  useful  modification  of  the  speculum  was,  I  believe,  first  suggested  by  Dr. 
"Warden,  London  and  Edinbu7-gh  Monthly  Journal,  Dec.  1844. 
*  CLinique  Chirurgicale,  &c.,  vol.  ii,  p.  272. 


EMPLOYMENT    OF    THE    SPECULUM.  31 

and  unsatisfactory.  To  obviate  these  disadvantages,  specula  have 
been  constructed  on  the  principle  of  the  old  instruments,  composed 
of  two,  three,  or  four  blades,  and  so  arranged  that  Ijy  turning  a 
screw  or  by  closing  the  handle,  the  uterine  extremities  separate, 
and  thus  expose  the  os  uteri  to  view  without  any  enlargement  of 
the  other  end  of  the  instrument.  The  best  known  of  them  are  the 
two-bladed  speculum  of  M.  Kicord;  a  three-  and  a  four-bladed 
speculum  manufactured  by  M.  Charriere,  of  Paris;  and  a  two- 
bladed  speculum  invented  by  Mr.  Coxeter,  instrument-maker  to 
University  College.  M.  Ricord's  instrument,  and  to  a  less  extent 
those  of  M.  Charriere,  have  the  inconvenience  that  folds  of  the 
vagina  are  apt  to  fall  down  between  the  blades,  and  thus  conceal 
the  OS  uteri  from  view.  This  objection  does  not  apply  to  nearly 
the  same  extent  to  Mr.  Coxeter's  instrument;  each  blade  of  which 
being  a  half-cylinder,  does  not  leave  so  large  a  space  vacant  when 
it  is  opened.  Two  or  three  different  sizes,  then,  of  Fergusson's 
speculum,  and  a  Coxeter's  bivalve  speculum — which  last  it  is  worth 
while,  for  the  sake  of  obtaining  a  better  reflecting  surface  to  have 
electro-plated — are  all  the  instruments  you  need  for  ocular  exami- 
nation of  the  uterus. 

On  the  Continent,  the  posture  usually  assumed  by  a  patient 
when  about  to  undergo  a  specular  examination,  is  on  the  back, 
with  the  nates  resting  on  the  edge  of  a  bed  or  table,  and  the  legs 
bent  up  towards  the  body,  or  the  feet  resting  on  two  chairs,  be- 
tween which  the  doctor  stands.  There  can  be  no  doubt  but  that 
in  this  position  of  the  patient  the  os  uteri  falls  more  readily  within 
the  orifice  of  the  speculum,  and  tliat  light  is  admitted  much  more 
thoroughly  than  in  any  other  attitude ;  but  its  apparent  indelicacy 
is  so  serious  an  objection  to  it,  that  except  under  special  circum- 
stances, it  is  desirable  to  introduce  the  speculum  with  the  patient 
lying  on  the  left  side.  In  this  position,  too,  unless  the  os  uteri  be 
directed  in  a  remarkable  degree  backwards  towards  the  sacrum,  a 
very  good  view  can  generally  be  obtained,  provided  the  patient  lie 
with  her  body  directly  across  the  bed,  her  hips  close  to  its  edge, 
and  her  thighs  drawn  up  towards  the  trunk;  in  the  same  attitude, 
indeed,  as  we  should  place  a  person  in,  on  whom  we  were  about 
to  appl}'  the  forceps  in  labor.  If  the  patient  be  not  in  bed,  the 
same  })recautions  as  to  her  position  must  be  taken  as  she  lies  on 
a  couch  or  sofa,  and  a  very  little  care  in  the  arrangement  of  her 
dress  will  prevent  any  exposure  of  her  person.  The  speculum, 
having  been  previously  warmed  and  lubricated,  is  then  to  be  in- 
troduced with  the  right  hand,  while  with  the  left  the  labia  and 
nymplue  are  separated.  Care  must  be  taken  that  the  end  of  the 
speculum  is  passed  thoroughly  within  the  opening  of  the  vulva, 
since,  if  this  precaution  be  neglected,  a  little  duplicature  of  the 
fourchctte  is  sometimes  pushed  before  the  instrument,  and  much 
needless  pain  is  caused  to  the  patient.  The  great  obstacle  to  the 
introduction  of  the  speculum  is  met  with  at  the  entrance  of  the 
vagina,  and  this  must  be  overcome  by  gentle  effort,  not  by  any- 
thing approaching  to  violence.     The  speculum  then  passes  on 


32  RULES    FOR    THE 

with  facility,  and  when  it  has  entered  for  some  distance  joii  with- 
draw the  plug,  and  possibly  find  that  the  os  uteri  is  now  within 
view.  You  must,  however,  bear  in  mind,  that  the  folds  of  the 
vagina  sometimes  hang  down  at  the  further  end  of  the  speculum, 
leaving  a  small  aperture  between  them,  which  may  be  mistaken 
for  the  OS  uteri ;  though,  on  moving  the  instrument  a  little,  the 
contour  of  the  orifice  will  alter,  and  the  vaginal  folds  dispose  them- 
selves in  a  difierent  form.  If,  although  you  have  introduced  the 
Bpeculum  for  some  distance,  the  os  uteri  do  not  appear,  the  proba- 
bilities are  that  you  have  passed  beyond  it,  and  that  the  instrument 
has  gone  up  into  the  cul-de-sac  of  the  vagina,  behind  the  neck  of 
the  womb.  In  this  case  by  gently  and  gradually  withdrawing  it, 
the  OS  uteri  will  most  probably  come  into  view ;  if  it  do  not,  you 
may  move  the  speculum  slightly  from  side  to  side,  since  it  is  likely 
that  the  uterus  is  not  quite  in  the  mesial  line,  and  that  thence 
arises  the  difiiculty  in  getting  sight  of  it.  When  once  you  have 
the  OS  uteri  within  the  speculum  a  little  manoeuvring  will  gener- 
ally suffice  to  remove  an}'  fold  of  vagina  which  obstructs  your 
view;  though,  if  the  neck  of  the  womb  be  very  large,  you  may 
be  compelled  to  examine  first  the  anterior  and  then  the  posterior 
lip  of  the  organ ;  and  in  this  case  you  will  find  a  bivalve  speculum 
much  more  useful  than  the  cylindrical  instrument. 

There  are  many  other  little  matters  of  detail  connected  with  the 
employment  of  tlie  si)eculum  well  worth  the  knowing,  but  to  be 
learned  rather  by  personal  observation  and  actual  practice  than  by 
any  description.  ISTeed  I  say  that  there  are  some  cases,  those  of 
unmarried  women,  for  instance,  in  which  nothing  but  the  most 
urgent  necessity  would  justify  your  employing  the  speculum; 
others,  as  the  majority  of  cases  of  cancer  of  the  womb,  in  which 
its  use  would  furnish  uo  important  addition  to  your  previous 
knowledge ;  and  still  others  in  which  its  employment  must  be 
postponed,  if  not  actually  interdicted — such,  for  instance,  as  cases 
of  extreme  sensibility  of  the  parts,  of  inflammation  or  ulceration 
of  the  vagina  or  of  the  external  organs?  Restrictions  to  its  use, 
indeed,  such  as  these,  speak  to  the  common  sense  and  right  feel- 
ing of  every  one  too  distinctly  for  there  to  be  much  hesitation  in 
subscribing  to  them.  But,  while  admitting  them,  some  of  you 
may  be  inclined  perhaps  to  go  still  further,  and  to  inquire  of  me, 
whether  on  the  whole,  the  advantages  arising  from  the  use  of  the 
speculum  outweigh  the  evils  resulting  from  its  abuse ;  whether  it 
helps  us  to  so  much  additional  knowledge,  or  adds  so  much  to  our 
therapeutical  resources,  as  to  counterbalance  all  the  suflering, 
both  moral  and  physical,  which  its  employment  not  infrequently 
inflicts  upon  the  patient?  ISTow  if  I  had  a  strong  opinion  on  the 
negative  side  of  this  question,  I  should  certainly  not  have  taken 
up  so  much  of  your  time  in  describing  the  instrument,  and  in 
directing  you  how  to  use  it.  The  restrictions  which  my  present 
experience  leads  me  to  put  upon  its  employment  will  be  best 
appreciated  when  I  speak  of  each  disease  in  the  management  of 
which  it  has  been  advised  to  have  recourse  to  it ;  and  whether  my 


EMPLOYMENT    OF    THE     SPECULUM.  33 

views  be  right  or  wrong,  I  do  not  apprehend  much  diiRculty  in 
expressing  them.  To  answer  the  broad  question,  "  What  is  your 
opinion  of  the  specukim?"  I  feel,  on  the  other  hand,  to  be  a  very 
difficult  matter,  and  to  expose  me  to  much  risk  of  being  misun- 
derstood. 

I  will,  however,  do  my  best  to  reply  to  the  inquiry.  Those  who 
first  introduced  the  speculum  into  practice  employed  it  for  two 
purposes;  partly  as  furnishing  a  new  means  of  diagnosis,  partly  as 
enabling  them  to  adopt  various  modes  of  local  treatment,  which, 
without  it,  were  impracticable.  Now  I  believe  that  the  advan- 
tages of  those  topical  medications  for  which  the  speculum  is  needed 
have  been  greatly  overrated ;  though  there  are  some  cases,  and 
those  such  as  have  proved  most  rebellious  under  other  plans  of 
treatment,  in  which  these  local  measures  may  be  resorted  to  with 
the  most  signal  advantage. 

In  estimating  the  value  of  the  speculum  as  a  means  of  diagnosis, 
I  think  that  the  advances  in  knowledge  of  uterine  disease,  of  which 
it  was  the  indirect  occasion,  by  the  impulse  which  it  gave  to  their 
study,  are  sometimes  confounded  with  those  positive  additions  to 
our  information  which  we  owe  exclusively  to  the  use  of  that  instru- 
ment. The  former  have  been  very  great  indeed,  and  I  think  candor 
compels  us  to  acknowledge  that  they  have  been  due  almost  exclu- 
sively to  persons  who,  not  content  with  our  previous  means  of 
investigating  uterine  disease,  have  labored  to  increase  them  by 
the  employment  of  instruments.  The  latter  have  certainly  been 
less  considerable,  but  nevertheless  the  speculum  enables  us  in 
many  instances  to  decide  at  once,  and  with  certainty,  upon  the 
nature  of  a  case,  which  otherwise  we  should  have  understood 
only  after  long  and  careful  watching,  to  discover  some  minute 
polypus  which  the  fingers  alone  would  not  have  detected,  to  deter- 
mine the  source  of  a  profuse  leucorrhoeal  discharge,  and  to  decide 
whether  it  is  furnished  by  the  cavity  of  the  womb,  or  by  the  walls 
of  the  vagina;  or,  from  the  redness,  congestion,  or  abrasion  of  the 
OS  uteri  to  infer  the  state  of  the  womb  generally,  and  thus  to 
conduct  our  treatment  upon  the  sure  ground  of  positive  observa- 
tion, not  upon  bare  presumptions.  At  the  same  time,  however, 
that  I  hold  the  speculum  to  be  in  many  cases  of  most  essential 
service,  I  think  that  the  endeavor  of  all  of  us  should  be  to  ascer- 
tain the  minimum  of  frequency  with  which  its  employment  is 
necessary.  This  is  to  be  done  not  by  decrying  the  instrument, 
still  less  by  attributing  dishonest  motives  to  those  who  use  it,  but 
by  soberly  and  honestly  trying  to  test  the  value  of  the  information 
which  we  derive  from  it,  and  learning  to  discriminate  between 
those  appearances  which  the  speculum  discloses  that  are  of 
moment,  and  such  as  are  of  no  importance. 


84  DISOKDERS  OF  MENSTRUATION. 


LECTURE    III. 

MENSTRUATION,  AND  ITS  DISOEDERS. 

Importance  of  disorders  of  menstruation  ;  their  three  varieties — Relation  of  tardy 
puberty  to  menstrual  disorder. 

Amenorkh(EA,  from  local  causes,  from  congenital  absence  or  malformation  of 
sexual  organs,  from  retention  of  menses  owing  to  impediments  to  their  flow. 

Amenorrhcea,  from  constitutional  causes — tardy  development,  influence  of  pre- 
vious illness  in  causing  it.  Symptoms,  chlorosis  whereon  it  depends — state  of 
the  blood.     Consequences  of  amenorrhcea. 

Treatment — principles  which  should  regulate  it — attention  to  general  health,  to 
uterine  functions.  Vicarious  hemorrhages,  their  import,  their  management. 
Importance  of  habit  in  all  ailments  of  menstrual  function. 

I  CALLED  your  attention,  in  the  first  Lecture,  to  the  importance 
of  the  menstrual  function,  and  to  the  frequency  of  its  disorders.  I 
told  you  that  almost  every  serious  ailment  of  the  generative  sys- 
tem, at  least  during  the  period  of  sexual  activity,  betrays  itself  by 
some  disturbance  of  menstruation;  and  I  may  further  add,  that 
such  disturbance  is  often  the  first,  and  sometimes  for  a  considera- 
ble period  the  only,  symptom  of  even  grave  disease.  But  you  also 
know  that  disordered  menstruation  does  not  invariably  depend  on 
local  mischief,  that  derangement  of  function  does  i^fOt  always  im- 
ply altered  structure,  but  that  a  woman  may  menstruate  scantily, 
painfully,  or  in  excess,  and  yet  no  part  of  her  generative  organs 
may  differ  in  appearance  from  those  of  a  person  in  whom  that 
function  has  always  been  performed  in  the  most  healthy  manner. 

The  disorders  of  the  menstrual  function,  then,  being  so  numer- 
ous, so  important,  and  dependent  on  such  various  causes,  it  will 
be  our  best  course  to  study  them  first,  and  afterwards  to  examine 
into  other  diseases  of  the  sexual  system,  in  which,  though  disor- 
dered menstruation  may  occur  as  a  symptom,  it  is  yet  not  the 
only  one,  nor  that  which  calls  for  the  chief  consideration  in  the 
treatment  of  the  patient. 

There  are  three  grand  classes,  to  one  or  other  of  which  it  has 
long  been  customary  to  refer  the  different  disorders  of  menstrua- 
tion. Either  the  menses  do  not  appear  at  that  period  of  life  at 
which  their  occurrence  is  naturally  expected,  or  they  become  sup- 
pressed in  persons  in  whom  they  have  already  occurred ;  or  their 
discharge  is  attended  with  extreme  pain  ;  or  it  is  excessive  in 
quantity,  or  over  frequent  in  its  return.  I  propose  to  consider  in 
its  turn  each  of  these  three  varieties  of  disordered  menistruation, 
which  have  respectively  received  the  names  of  Amenorrhcea,  Dys- 
menorrhoea,  and  Menorrhagia. 

It  is,  as  you  know,  wisely  ordered  that  the  power  of  perpetuat- 
ing the  species  is  the  last  of  nature's  gifts,  and  one  which  she  does 
not  accord  until  the  whole  system  has,  in  other  respects,  attained 


TARDY    PUBERTY. 


60 


nearly  to  its  perfection.  Of  this  new  power  in  woman,  menstrua- 
tion is  both  the  sign  and  the  consequence,  indicating;  that  tlie 
ovaries  have  become  capable  of  bringing  to  maturity  the  germs, 
which  need  only  to  be  impregnated  in  order  to  become  developed 
to  new  beings.  In  our  climate,  the  date  of  the  first  occurrence  of 
menstruation  is  between  the  fifteenth  and  sixteenth  year ;'  but  the 
changes  at  puberty  in  the  maiden,  like  those  at  dentition  in  the 
babe,  are  not  accomplished  all  at  once,  but  extend  over  a  period 
of  several  months,  during  which  disease  is  more  frequent,  and  as 
our  Tables  of  Mortality  show,  more  fatal,  as  compared  with  the 
male  sex,  than  at  any  former  time.^  The  anxiety  with  which  pa- 
rents regard  the  approach  of  this  epoch  is,  then,  not  unnatural ; 
nor  is  it  without  good  reason  that  this  anxiety  is  increased  more 
and  more  in  proportion  as  delay  occurs  in  the  appearance  of  the 
first  menstruation,  since,  when  the  menstrual  function  has  been 
even  once  properly  performed,  many  of  the  dangers  of  puberty 
may  be  regarded  as  already  passed. 

i)r.  Whitehead,  of  Manchester,  to  whom  the  profession  is  in- 
debted for  some  very  interesting  researches  into  these  subjects,  as- 
certained that  the  risk  of  some  unfavorable  accident  complicating 
the  first  establishment  of  menstruation  is  very  much  greater  when 
that  is  tardy  in  its  occurrence  than  when  it  is  premature ;  and  that 
in  between  a  third  and  half  of  all  cases  in  which  it  is  delayed  to 
nineteen  years  and  upw^ards,  its  appearance  is  associated  with 
either  local  or  constitutional  disorders — a  statement  with  which 
my  own  experience  coincides.^ 

1  Dr.  Whitehead,  of  Manchester,  gives  fifteen  years  six  and  three-quarter 
months  as  the  avera!ji;c  deduced  from  4000  cases,  in  which  he  made  this  point  the 
subject  of  inquiry.  See  p.  47  of  his  Treatise  on  Abortio7i  and  Sterility^  8vo.,  Lon- 
don, 1847. 

2  Thus  MM.  Quetelet  and.  Smits,  in  their  work  Sur  la  Reproduction  et  la  Morta^ 
lit&  de  V Homme,  8vo.,  Bruxelles,  1832,  show  that  while  in  childhood  the  mortality 
of  the  two  sexes  has  been  equal,  or  that  of  the  male  has  predominated,  the  female 
mortality  at  once  rises  between  fourteen  and  eighteen  years  of  age  to  1.28  to  1 
male  death  ;  sinking  again  in  tlie  succeeding  four  years  to  the  proportion  of  1.05 
female  to  1  male  death. 

*  Mr.  Whitehead's  table,  lib.  cit.  p.  48,  yields  the  following  results: 


First  Menstruation. 

Total  Number  of 
Cases. 

Number 
Unfavorable. 

Percentasre  of 
Unfavorable. 

From  10  to  14  years, . 
Between  15  ai\d  IG,    .     . 
"         17  and  18,    .     . 
From  19  and  upwards,   . 

Total, 

1141 

1728 
892 
239 

224 
324 
247 

'J  7 

19.03 
18.75 
27.69 
40.58 

4000 

892 

22.30  av. 

In  506  cases  in  which  I  ascertained  the  date  of  the  first  menstruation,  cither  ex- 
cessive pain,  excessive  discharge,  irregularity  of  its  return,  or  disorder  of  the 
general  health,  occurred  with  the  frequency  shown  in  the  following  table.     The 


36 


AMENORRHCEA, 


The  mere  circumstance,  indeed,  of  a  girl  having  passed  the  age 
at  which  menstruation  usually  appears,  without  performing  that 
function,  is  not  of  itself  a  reason  for  medical  interference.  The 
date  of  puberty  varies  very  widely,  and  one  woman  may  menstru- 
ate at  ten,  and  another  at  twenty  years  of  age,  without  the  health 
of  either  being  of  necessity  impaired.  Usually  the  absence  of 
menstruation  in  otherwise  healthy  young  women,  is  associated 
with  the  absence  of  some  of  the  other  signs  of  puberty,  indicating 
a  generally  tardy  sexual  development,  just  as,  without  apparent 
cause,  one  tree  will  produce  blossoms  and  bear  fruit  later  than 
another.  This,  however,  is  not  always  the  case,  and  instances  are 
sometimes  met  with  of  persons  in  whom  pregnancy  has  preceded 
menstruation  :  completeness  of  sexual  power  having  existed, 
though  not  manifesting  itself  by  its  ordinary  sign.  Such  cases 
were  a  greater  puzzle  to  physicians  in  former  days  than  they  are 
to  us,  who  know  that  the  discharge  of  blood  is  not  the  essential 
part  of  menstruation,  but  that  the  maturation  and  extrusion  of 
ova  may  occur  independently  of  it.  One  instance  of  it  has  come 
under  my  own  notice,  in  a  woman  who,  never  having  menstruated, 
married  at  the  age  of  twenty,  and  immediately  became  pregnant; 
nor  did  the  menses  appear  till  after  the  birth  of  the  first  child, 
though  she  subsequently  menstruated  regularly,  and  had  a  numer- 
ous family.  This,  however,  is  very  rare,  and  there  would  always 
be  reason  to  apprehend  that  a  woman  who  had  not  menstruated 
before  marriage  would  remain  sterile  afterwards.  Besides,  it  is 
possible  that  the  non-appearance  of  the  menses  depends  upon 
some  congenital  malformation,  which  might  even  prove  a  bar  to 
sexual  intercourse,  such  as  absence  of  the  vagina  or  its  imperfect 
formation.  If,  then,  your  advice  be  asked  as  to  the  propriety  of 
any  young  person  marrying  who  has  not  menstruated,  I  should 
advise  you  to  recommend  delay  ;  and  if  still  further  urged,  to 
withhold  your  sanction  until  you  have  ascertained  that  no  serious 
defect  of  structure  is  present.  The  pain  of  such  an  investigation 
would  foil  far  short  of  the  distress  which  would  be  entailed  upon 
all  parties,  if  a  woman  with  some  important  malformation  of  her 
sexual  organs  were  to  contract  marriage.' 

conclusions  to  which  it  leads  are  the  same  as  follow  from  Mr.  Whitehead's  more 
extended  researches  : 


First  Menstruation. 

Unfavorable. 

percentage  of 
Unfavorable. 

Under  15, 

Between  15  and  17,    .     . 

17  and  19,    .     . 

At  19  and  upwards,   .     . 

Total, 

228 

220 

92 

26 

41 
38 
22 
11 

17.9 
15. 
23.9 
46.1 

566 

107 

25.7  av. 

^  An  important  case  illustrative  of  this  subject  is  related  by  Dr.  Meigs,  at  p.  119 
of  his"8ranslation  of  Colombat  on  Diseases  of  Females,  8vo.     Philadelphia,  1845. 


FROM    MALFORMATION.  37 

Amenoi'rhcea  from  imperfect  formation  of  the  sexual  organs  may 
depend  either  upon  causes  which  altogether  prevent  the  perfor- 
mance of  the  menstrual  function,  or  on  such  as  merely  interfere 
with  the  discharge  of  the  menstrual  fluid.  Cases  of  the  former 
kind  are  fortunately  very  rare,  since,  depending  on  the  absence  or 
defective  formation  of  the  uterus  or  ovaries,  they  are  completely 
bej'ond  the  reach  of  remedy  ;  those  of  the  latter  description  gene- 
rally admit  of  cure.  In  some  of  the  former  class  of  cases,  the 
sexual  character  has  been  altogether  imperfectly  developed,  and 
the  woman  has  never  experienced  any  periodical  occurrence  of 
symptoms  such  as  usually  prelude  the  appearance  of  the  menses,, 
while  in  others  the  women  have  been  liable  to  periodical  attacks  of 
pain  in  the  back  and  loins,  and  to  all  those  indications  of  suffering 
by  which  the  menstrual  flux  is  often  attended,  and  have  presented 
in  their  outward  form  all  the  indications  of  perfect  womaidiood. 
It  is  not  easy  to  account  for  all  of  these  difterences,  since,  in  some 
instances,  where  the  sexual  character  was  but  imperfectly  marked, 
the  ovaries  were  found  after  death  sufliciently  well  formed,  though 
the  uterus  was  absent,  or  merely  rudimentary. 

A  few  casQS  are  on  record  of  alleged  absence  of  both  ovaries, 
in  spite  of  the  otherwise  natural  formation  of  the  sexual  organs. 
Such  cases,  however,  are  excessively  rare,  and  the  probabilities 
are  that  in  many  instances  the  organs  were  present,  though  in  a 
very  undeveloped  condition.  Somewhat  less  uncommon  are  the 
instances  of  absence  of  one  ovary  ;  a  malformation  generally  asso- 
ciated with  absence  of  the  other  uterine  appendages  on  the  same 
side,  and  sometimes  also  with  absence  of  the  corresponding  kid- 
ney: a  circumstance  which  will  not  surprise  you  if  you  bear  in 
mind  the  mode  of  development  of  the  urinary  and  generative  ap- 
paratus, and  the  intimate  relation  which  subsists  between  them  at 
an  early  period  of  foetal  existence.  Much  less  uncommon  than 
the  absence  of  either  ovary  is  the  persistence  of  both  through  the 
whole  or  the  greater  part  of  life  in  the  condition  which  they 
present  in  inftincy  and  early  childhood,  with  scarcely  a  trace  of 
Graafian  vesicles  in  their  tissue.  This  want  of  development  of 
the  ovaries  is  generally,  though  not  invariably  associated  with 
want  of  development  of  the  uterus  and  other  sexual  organs:  and 
I  need  not  say  that  women  in  whom  it  exists  are  sterile. 

Two  instances  have  come  under  my  own  notice  in  which  there 
was  reason  to  suppose  that  some  defect  of  development  of  the 
ovaries  was  present.  The  first  patient  was  a  woman  aged  forty- 
three,  who  had  been  married  for  twenty  years,  but  had  never 
menstruated,  nor  had  ever  been  pregnant.  In  her  case  the  sexual 
organs  were  well  formed,  though  the  uterus  was  small,  and  sexual 
appetite  existed.  The  other  case  was  that  of  a  young  girl  about 
twenty  years  of  age,  wlio  was  for  some  time  under  the  care  of  the 
late  Dr.  Roupell,  suflcring  from  those  vague  symptoms  of  disorder 
of  the  general  health  which  so  frequently  exist  when  the  appear- 
ance of  the  menses  is  delayed.  She  presented  the  generaJi*£igiig 
of  puberty,  but  her  vagina  was  very  small,  and  her  uterus  was  not 


38  AMENORRHCEA, 

larger  than  that  of  a  young  cliild.  I  do  not  know  what  became 
of  her  eventually,  but  it  is  quite  possible  that  the  evolution  of  her 
sexual  organs,  though  long  delayed,  may  at  length  have  taken 
place,  and  have  been  followed  by  the  due  performance  of  their 
functions. 

Conditions^  such  as  these  which  I  have  been  speaking  of  interest 
us  rather  as  physiologists  than  as  practitioners  ;  we  can  only  guess 
at  their  existence,  and  can  do  nothing  for  their  remedy.  Though 
not  so  obscure,  still  quite  as  hopeless  are  those  cases  in  which  the 
uterus  alone  is  absent,  or,  as  is  more  frequently  the  case,  is  repre- 
sented by  one  or  two  small  bodies,  of  the  bigness  of  a  bean,  or 
even  smaller,  made  up  of  true  uterine  tissue,  rudiments,  as  it  were, 
of  the  deficient  organ.  This  absence  of  the  uterus  may  coexist 
with  a  perfectly  natural  condition  of  the  external  organs ;  .the 
"\^gina,  which  is  usually  much  shorter  than  natural,  terminating 
in  a  cul-de-sac.  The  only  instance  of  this  malformation  which  I 
have  seen,  existed  in  a  young  woman  of  little  more  than  twenty 
years  of  age,  who  had  been  married  but  a  few  months,  and  who 
applied  to  the  late  Dr.  Hugh  Ley,  in  consequence  of  some  obstacle 
to  complete  sexual  intei'course.  Her  appearance  was  that  of  a 
well-developed  woman,  and  her  external  genitals  were  quite  nat- 
ural, but  the  vagina  was  not  above  an  inch  and  a  half  in  length, 
and  terminated  in  a  blind  pouch,  above  which  no  uterus  could  be 
felt,  neither  could  any  trace  of  the  organ  be  discovered  on  exam- 
ination by  the  rectum.^ 

Besides  these  cases,  however,  in  which  the  non-appearance  of 
the  menses  is  due  to  a  cause  wholly  beyond  the  power  of  art  to 
remedy,  there  are  others  in  wliich  the  ovaries  are  present,  and 
perform  their  functions  properly,  in  which  the  uterus  also  exists, 
and  the  periodical  hemorrhage  takes  place  from  its  lining ;  but 
the  effused  blood  finds  no  means  of  escape,  owing  to  congenital 
closure  of  the  os  uteri,  or  to  the  absence  or  occlusion  of  the  vagina. 

The  non-appearance  of  the  menses  from  any  of  these  causes  is 
unquestionably  very  rare,  and  but  one  instance  of  imperforate  state 
of  the  hymen  has  come  under  my  observation.  To  judge  by  the 
recorded  accounts  of  such  cases,  however,  they  all  present  a  certain 
general  resemblance  to  each  other,  and  are  all  characterized  by 
the  occurrence,  at  or  soon  after  the  ordinary  period,  of  the  usual 
signs  of  puberty,  the  appearance  of  the  menses  alone  excepted. 
While  these  are  absent,  the  premonitory  symptoms,  which  in 
general  usher  them  in,  are  experienced  with  even  more  than  ordi- 
nary severity.     These  symptoms  subside,  and  again  recur  after 

1  Numerous  references  to  cases  of  absence  of  the  ovaries,  or  of  their  imperfect 
development,  are  to  be  found  in  Chereau,  TraiU  des  Maladies  des  Ovaires,  Paris, 
1844,  pp.  73-91 ;  and  Meissner,  Frauenkrankheiten,  vol.  ii,  p.  28 ;  and  Dr.  Thndi- 
cum,  of  London,  has  published  in  the  Monatschrij't  f.  Oeburtfiku7ide,  April,  1855, 
p.  272,  a  very  careful  analysis  of  twenty-one  cases,  collected  from  different  sources, 
in  which  the  uterus  was  either  altogether  absent,  or  merely  rudimentary. 

*  Any  one  who  wishes  to  study  the  subject  of  uterine  malformations  in  all  its 
bearii^^  will  find  ample  materials  collected  in  the  elaborate  work  of  Kussmaul, 
Von  d^  Mangel,  der  Verkummerung,  <J-c.,  dei'  Gebarmutter,  8vo.,  Wiirzburg,  1859. 


FKOM    MALFORMATION.  39 

the  lapse  of  about  a  menstrual  interval,  till,  after  many  months, 
enlargement  of  the  abdomen  becomes  apparent,  and  increases  by 
degrees  with  each  periodical  exacerbation  of  the  patient's  suffer- 
ings. 

The  history  of  the  patient,  the  absence  of  menstruation  long 
after  the  period  when  it  usually  shows  itself,  and  this  in  spite  of 
the  occurrence  of  the  constitutional  symptoms  which  generally 
accompany  it,  when  coupled  with  the  progressive  enlargement  of 
the  abdomen,  lead  in  the  course  of  time  to  the  cause  of  the  symp- 
toms being  recognized,  and  to  surgical  means  being  adopted  for 
their  removal.  iStill,  there  are  several  circumstances  which  concur 
to  prevent  the  abdominal  enlargement  from  becoming  apparent  so 
early,  and  from  attaining,  even  after  a  long  lapse  of  time,  to  so 
great  a  size,  as  might  at  first  have  been  anticipated.  Wherever 
any  mechanical  obstacle  exists  to  the  outflow  of  the  menses,  they 
are  almost  invariably  poured  out  in  far  smaller  quantity  than 
natural — a  fact  which  I  shall  have  again  to  refer  to  wlien  I  have 
to  speak  of  some  forms  of  dysmenorrhcea.  In  the  next  place,  it 
must  not  be  supposed  that  the  blood  poured  out  into  the  uterine 
cavity  collects  there  uninfluenced  by  the  vital  processes  which  go 
on  in  the  rest  of  the  economy.  On  the  contrary,  the  absorbents 
are  very  active  in  getting  rid  of  the  efi'used  blood;  and  microscopic 
examinations  show  that  it  undergoes  alterations  of  the  same  kind 
as  take  place  in  blood  poured  out  elsewhere,  and  is  removed  by  a 
similar  process.^  But  besides  this,  the  blood  itself  seems  in  some 
instances  to  escape  through  the  flmbriated  extremities  of  the  Fal- 
lopian tubes  into  the  abdominal  cavity,  where  sometimes  it  is  ab- 
sorbed without  giving  rise  to  any  dangerous  symptoms,  though,  in 
other  cases,  fatal  peritonitis  has  followed  this  occurrence.^ 

One  other  caution  with  reference  to  these  cases  may  not  be  out 
of  place  here,  and  that  concerns  the  prognosis  which  we  may  ex- 
press with  reference  to  the  result  of  any  operation  for  their  cure. 
Though  generally  favorable,  it  yet  must  be  borne  in  mind,  that  a 
fatal  result  due  to  the  occurrence  of  inflammation,  has  sometimes 
followed  an  operation  as  simple  as  the  mere  division  of  an  imper- 
forate hymen  ;  and  that  this  has  in  some  instances  been  produced 
by  blood  being  poured  through  the  Fallopian  tubes  into  the  ab- 
dominal cavity — notwithstanding  that  an  opening  in  the  vagina 
existed  of  ample  size  to  allow  of  its  ready  escape  in  the  natural 
way.^ 

1  Seo  the  interesting  account,  by  Dr.  H.  Miiller,  of  his  examination  of  the  re- 
tained menstrual  blood  in  two  cases  of  congenital  atresia  vaginte,  in  Henle  and 
Pfcutlcr's  Zcitschrift,  vol.  v,  184G,  p.  140. 

^  A  series  of  papers,  by  ^I.  Bernutz,  in  the  Archives  de  Medrdne  for  June, 
August,  and  December,  1848,  and  for  November,  1849,  bear  on  tliis  subject,  and 
may  be  consulted  with  advantage.  These  pa})ers  will  be  found  reproduced  in  a 
more  extendi  d  form,  and  with  many  additional  observations,  in  the  tirst  volume 
of  the  work,  Sur  les  Maladies  des  Fcmmes,  8vo.,  Paris,  1800,  published  by  him  in 
conjunction  with  M.  Goupil. 

*  As  in  a  case  related  by  M.  Marchand  de  Mass^,  in  the  Archir<es  de^^decine, 
July,  1851,  in  several  collected  by  M.  Bernutz,  lih.  cit.,  and  in  one  w|^^^ame 
under  my  own  cognizance  at  Bartholomew's  Hospital. 


deM^Uc 


40  AMENORRH(EA, 

Attacks  of  inflammation  of  the  sexual  organs  in  women  wlio 
have  ah'eacly  menstruated,  and  have  even  ah-eady  borne  children, 
are  sometimes  followed  by  amenorrhoea;  either  from  abiding  mis- 
chief inflicted  on  the  ovaria  altogether  putting  a  stop  to  the  per- 
formance of  the  function,  or  from  cohesion  between  the  edges  of 
the  OS  uteri,  or  agglutination  of  the  walls  of  its  cervix,  or  from 
injury  to  the  vagina,  sloughing  of  its  walls,  and  subsequent  oblit- 
eration  of  its  canal.  In  some  of  these  cases,  as  in  cases  of  con- 
genital malformation,  the  menstrual  fluid  may  collect  within  the 
cavity  of  the  womb,  and  require  to  be  evacuated  by  a  surgical  pro- 
ceeding. Mere  obstruction  of  the  passages  through  which  the 
menstrual  discharge  ought  to  flow,  seems,  however,  to  be  some- 
times followed  by  its  complete  suppression.  I  have  known  the 
menses  permanently  to  cease  after  severe  labor,  followed  by  oblit- 
eration of  the  OS  uteri  and  adhesion  between  the  vaginal  walls, 
even  though  there  was  no  reason  for  supposing  that  either  the 
body  of  the  womb  or  the  ovaries  had  been  the  seat  of  any  serious 
inflammatory  mischief. 

Though  I  have  made  these  few  remarks  on  the  non-appearance 
or  suppression  of  the  menses  from  causes  requiring  surgical  inter- 
ference, I  wish  to  cull  your  attention  chiefly  to  cases  of  amenorrhoea 
from  causes  which  require  the  interference  of  the  physician. 

But  before  going  into  any  details  on  this  subject,  I  will  once 
more  remind  you,  that  the  mere  postponement  of  the  appearance 
of  the  menses  beyond  the  time  at  which  they  usually  show  them- 
selves, does  not  of  itself  call  for  interference,  does  not  even  warrant 
anxiety.  Like  all  the  other  processes  of  development,  so  that  of 
the  generative  system  admits  of  considerable  variations  in  point 
of  time  without  of  necessity  passing  the  limits  of  health.  Indeed, 
just  as  one  child  cuts  its  first  tooth  at  seven  months,  and  another 
not  till  a  year  old,  so  one  girl  may  menstruate  at  fourteen  or  fifteen 
years  of  age,  and  another  not  till  seventeen,  without  any  obvious 
reason  existing  for  the  early  performance  of  the  function  in  the 
one  case,  or  for  its  tardy  accomplishment  in  the  other.  Mothers 
are  often  anxious  about  their  children,  if  they  do  not  menstruate 
till  somewhat  later  than  the  average  period ;  or  even  as  that 
period  approaches,  will  often  attribute  to  its  influence  the  most 
diverse  symptoms  of  disordered  health  ;  and  will  urge  on  you 
the  employment  of  emmenagogue  medicines  as  essential  to  their 
removal. 

Again,  the  occurrence  of  serious  illness  of  almost  any  kind  a  few 
months,  or  even  a  few  years,  before  the  arrival  of  the  period  of 
puberty,  will  often  postpone  for  a  long  time  the  manifestation  of  its 
signs,  and,  in  particular,  the  appearance  of  the  menses.  Not  long 
since  I  saw  a  young  woman,  twenty  years  of  age,  who  had  never 
menstruated,  who,  perhaps,  never  will.  Her  health  had  been  good 
until  she  experienced  a  severe  attack  of  scarlet  fever  at  the  age  of 
fifteen.  Her  recovery  from  this  illness  had  been  very  slow,  and  she 
was  dwarfed  by  it  in  body,  and  apparently  in  mind  too,  and  her 
feeble  frame  was  unequal  to  the  task  of  bringing  her  reproductive 


IN    OPPOSITE    STATES    OF    THE    SYSTEM.  41 

powers  to  perfection.  In  idiots,  with  wliom  the  imperfect  develop- 
ment of  mind  is  generally  associated  with  imperfect  development 
of  body,  puberty  is  almost  always  late  in  its  occurrence.  It  appears, 
too,  from  the  ehiborate  Report  on  Cretinism,  presented  to  the  Sar- 
dinian Government  in  1848,  that  in  extreme  degrees  of  that  con- 
dition, the  reproductive  powers  are  never  developed  at  all ;  in  less 
degrees,  menstruation  appears  late,  and  continues  scanty  and  irreg- 
ular through  life  ;  while  even  in  cases  of  the  slightest  description, 
the  average  date  of  the  first  menstruation  is  as  late  as  the  eighteenth 
year.^ 

Further,  even  when  there  is  no  bodilj^  disease,  nor  any  local  cause 
rendering  impossible  the  due  performance  of  the  sexual  functions, 
it  nmst  yet  be  borne  in  mind  that  those  functions  are  seldom  com- 
pletely performed  from  the  very  moment  when  they  give  the  first 
indication  of  their  activity.  It  oftens  happens,  that  after  the  first 
menstruation  there  is  an  interval,  not  of  one  month,  but  of  two  or 
three,  before  tlie  menses  again  make  their  appearance  ;  or,  perhaps, 
that  the  signs  premonitorj'  of  menstruation  are  followed  by  a  dis- 
charge, not"  of  blood,  but  of  mucus,  the  menstruce  alhce  of  old 
writers.  "VVe  know  that  such  discharges,  though  once  regarded  as 
morbid,  are  far  from  being  necessarily  so.  If  the  congestion  of 
the  uterus  attending  the  menstrual  efibrt  be  slight,  the  quantity  of 
blood  poured  out  from  the  organ  will  be  but  small,  and  mucus  and 
epithelium  corpuscles  will  then  make  up  the  bulk  of  the  discharge. 
In  such  a  case,  however,  menstruation  may  be  as  really  performed, 
as  in  the  woman  from  whose  sexual  organs  hemorrhage  takes  place 
with  the  greatest  abundance.  Time  rarely  fails  to  bring  the  func- 
tion, in  a  few  months,  to  the  strictest  conformity,  in  all  respects, 
to  those  laws  by  which  it  is  governed  in  the  healthy  and  fully 
developed  woman. 

Still,  after  every  allowance  has  been  made  for  cases  of  mere  tardy 
development,  and  for  those  in  which  the  complete  performance  of 
the  sexual  functions  is  accomplished  by  degrees,  as  well  as  for 
others  in  which  the  activity  of  the  reproductive  powers  is  [»ost- 
poned  almost  indefinitely  by  previous  bodily  ailment,  tliere  yet 
remain  a  number  of  instances  where  the  non-accomplishment  of 
the  menstrual  process,  at  the  time  when  the  changes  of  puberty 
are  usually  completed,  is  the  prominent  sym))tora  of  disordered 
health,  and  seems  to  be  the  chief  occasion  of  all  the  various  forms 
of  illness  with  which  it  may  be  associated. 

There  are  tivo  different  chisses  of  f!i/mpto)ns,with  one  or  the  other 
of  which  the  non-appearance  of  the  menses  is  in  these  cases  usually 
associated — S3'm[)tom3  difi'ering  widely  in  their  general  characters, 
but  probably  far  less  widely  separated  in  their  essential  causes. 
In  the  one  case  the  condition  is  apparently  of  plctJiora,  in  the  other 
of  anannia  ;  but  the  tendency  of  the  former  is  to  pass  into  the 
latter,  and  this  transition  often  takes  place  very  rapidly. 

'  Ritpport  ife  la  Coimnission  crie  par  S.  M.  le  Roi  de  Sanlaigne  pour  etudUr  la 
C'retinisme,  4to.,  Turin,  1848,  see  p.  25.  ^ 


42  AMENORRHCEA, 

A  girl,  previously  in  good  health,  approaches  the  time  of 
puberty ;  some  of  the  changes  characteristic  of  it  take  place,  the 
form  assumes  the  contour  of  womanhood,  and  nothing  but  the 
occurrence  of  menstruation  is  wanting  to  announce  the  comple- 
tion of  the  change.  The  menses,  however,  do  not  show  them- 
selves, but  the  girl  begins  to  suffer  from  frequent  headache  and  a 
flushed  face,  frequent  backache,  pain  in  the  hypogastrium,  and 
constipated  bowels,  a  furred  tongue  and  a  full  pulse,  and  all  these 
signs  of  constitutional  disorder  undergo  a  marked  increase  at 
stated  periods  of  about  a  month.  At  length  menstruation  occurs, 
though  in  all  probability  scantily,  and  attended  with  much  pain, 
and  then  for  several  months  togetlier  there  is  no  sign  of  its  return  ; 
or,  perhaps,  when  the  proper  period  comes  round  again,  the  bleed- 
ing, instead  of  taking  place,  as  it  ought  to  do,  from  the  womb, 
occurs  from  the  stomach,  or,  less  frequently,  from  the  intestines. 
The  general  health  was  at  first  probably  not  seriously  disturbed, 
or  at  least  its  disorder  was  limited  to  certain  times  of  peculiar 
suffering,  but  by  degrees  the  patient  becomes  habitually  ailing, 
the  appetite  falls  off,  the  powers  of  digestion  are  weakened,  the 
strength  becomes  unequal  to  ordinary  exertion,  the  pulse  grows 
feeble  and  frequent,  and  the  face  itself  assumes  the  pallid  sallow 
tinge  whence  the  term  cldorosis  has  been  selected  as  the  most  ap- 
propriate designation  of  the  condition  ;  while  the  stethoscope  de- 
tects a  peculiar  sound  attendant  on  the  passage  of  the  blood 
through  the  cavities  of  the  heart  and  along  the  arterial  and  venous 
trunks,  and  which  is  known  to  l)e  significant  of  changes  in  its  com- 
position, often  of  diminution  of  its  quantity. 

In  other  instances,  the  signs  of  plethora  have  not  at  any  time 
been  present,  but  the  health,  never  very  robust,  fails  more  and  more 
as  the  period  of  puberty  approaches;  the  feeble  pulse,  the  cold 
skin,  the  bloodless  countenance,  the  deficient  and  depraved  ap- 
petite come  on  by  degrees,  while  the  outward  signs  of  puberty 
appear  slowly  and  imperfectly.  The  frail  child  never  passes  com- 
pletely into  womanhood,  but  fades  and  droops  in  the  transition 
stage,  through  which  she  has  not  strength  to  pass. 

In  cases  of  both  these  kinds  there  is  unquestionably  a  certain 
degree  of  obscurity,  though  scarcely  more  than  we  should  find  in 
the  endeavor  to  explain  how  in  infancy  the  state  of  the  general 
health  influences  dentition,  or  the  process  of  teething  reacts  on  the 
general  health.  The  weakly  child  cuts  its  teeth  painfully,  tardily, 
irregularly  ;  and  there  seems  to  be  no  essential  difierence  between 
cases  in  which  the  health  foils  oti"  before  any  teeth  have  actually 
appeared,  and  those  in  which  the  symptoms  come  on  after  one  or 
two  of  the  teeth  have  cut  through  the  gum.  In  both  cases  we 
look  beyond  the  local  phenomena  for  the  explanation  of  the  symp- 
toms ;  and  we  do  the  same  in  the  girl  at  puberty  as  in  the  infant 
in  whom  the  period  of  dentition  has  commenced. 

In  the  case  of  the  girl  at  puberty  there  seems,  however,  to  be 
another  element  to  be  taken  into  consideration, — namely,  the  com- 
po3itif)n  of  the  blood.     Of  all  the  various  processes  of  development 


ITS    RELATION    TO    CHLOROSIS.  43 

which  at  clifierent  times  go  on  in  the  system,  none  seem  to  make 
sucli  great  demands  upon  the  circuLating  fluid  as  those  which  con- 
cern the  reproductive  organs.  During  pregnancy,  even  in  a  healthy 
woman,  certain  changes  in  the  blood  (a  diminution  of  its  red  par- 
ticles, an  increase  in  its  watery  elements)  are  of  constant  occur- 
rence ;  while  in  some  instances  these  changes  are  so  considerable 
as  to  give  rise  to  disorder  of  the  general  health  precisely  similar 
in  all  its  characters  to  chlorosis.^  The  growth  of  the  womb,  the 
development  of  the  foetus,  are,  indeed,  accomplished,  for  they  are 
subject  to  a  law  not  easily  broken  through  ;  but  they  are  accom- 
plished at  the  expense  of  the  woman's  constitution,  and  leave  her 
often  incapable  of  suckling  her  infant,  and  probably  liable  to  all 
that  class  of  inflammatory  aifections,  the  remote  cause  of  which, 
as  of  phlegmasia  dolens,  for  instance,  is  to  be  sought  in  some 
morbid  state  of  the  blood. 

To  originate  a  new  function,  to  bring  to  perfection  a  hitherto 
unexercised  power,  makes  larger  demands  on  the  strength  than 
are  required  for  its  continued  activity.  The  feeble  phthisical  child 
fails,  as  the  time  of  womanhood  approaches,  to  menstruate,  and 
the  signs  of  chlorosis  gradually  manifest  themselves  in  her,  while 
in  spite  of  advanced  tubercular  disease,  the  grown  woman  some- 
times continues  to  menstruate  with  regularity,  or  even  to  bring 
forth  children.  These,  however,  are,  it  must  be  confessed,  excep- 
tional occurrences ;  the  tendency  of  almost  all  diseases  which 
originate  in,  or  in  their  course  produce  important  alterations  in 
the  blood,  is  to  disturb,  to  impair,  and  at  length  to  interrupt  the 
performance  of  the  reproductive  functions.  In  one  instance  only,^ 
out  of  all  the  cases  of  phthisis  among  women  that  form  the  mate- 
rials of  M.  Louis'  great  work  on  that  disease,  did  menstruation 
continue  up  to  the  time  of  death ;  and  it  suffices  to  watch  with 
moderate  care  any  one  suffering  from  uterine  cancer  in  order  to 
feel  satisfied,  that  even  though  hemorrhage  may  still  occasionally 
take  place  from  the  diseased  womb,  yet  the  periodical  activity  of 
the  reproductive  organs  ceased  when  once  the  cancerous  cachexia 
had  become  developed. 

There  is  another  peculiarity  connected  with  the  sexual  functions 
in  woman  which  must  not  be  left  altogether  w^ithout  notice,  since 
it  suggests  a  reason  why  their  tardy  or  imperfect  development,  or 
their  subsequent  disorder,  should  be  associated  with  symptoms  to 
which  we  nowhere  else  find  the  slightest  analogy.  It  is  a  law  of 
the  female  economy  that  for  some  thirty  years  of  life,  unless  in- 
terrupted by  pregnancy  or  its  results,  a  certain  quantity  of  blood 
shall  be  periodical  1}'-  discharged  from  the  system.    This  periodical 

'  The  merit  of  the  first  observations  on  chlorosis  in  pregnancy  must  be  divided 
between  M.  Cazcaux,  of  Paris,  and  the  hitc  Professor  von  Kiwisch,  of  Prague, 
though  the  claims  of  the  latter  appear  to  be  the  stronger.  The  best  remarks  on 
the  subject  will  be  found  in  Cazeaux,  Traiie  des  Afcouchnnena,  Paris,  1850,  jip. 
2'J1-301  ;  Kiwisch,  Die  Gehu7-isknmle,  Erlangen,  1851,  vol.  i,  p.  221,  and  vol.  ii,  p. 
3;i  ;  and  Scanzoni,  Lehrbuch  der  Geburts/iul/e,  Vienna,  1849,  vol.  i,  p.  102. 

2   Louis,  Recherehes  sur  la  Phlhiaie,  deuxifcrac  ed.,  8vo.,  Paris,  1843,  p.  334. 


44  AMENORRHCEA, 

discbarge  alone  engaged  the  attention  of  observers  in  bygone 
times,  and  various  b3'potbeses  were  framed,  which,  differing  in 
other  respects,  yet  agreed  in  this, —  that  they  all  regarded  the 
menstrual  function  as  a  great  depurative  agent,  a  means  supple- 
mental to  the  lungs  themselves,  for  eliminating  superfluous  carbon 
from  the  system.  Though  we,  with  the  light  of  modern  physi- 
olog3%  are  able  to  look  deeper  than  our  predecessors,  and  can  see 
in  the  discharge  of  blood  from  the  sexual  ors^ans  the  outward 
sign  of  a  still  more  important  process  ^oing  on  within,  we  j-et 
must  not  forget  that  it  cannot  be  a  matter  of  indifference  to  the 
health  of  a  woman  whether  excretion  of  four  or  six  ounces  of 
blood  takes  place  every  month,  or  not;  that  the  arrest  of  this 
phenomenon  or  its  non-occurrence  cannot  but  be  associated  with 
much  constitutional  disorder.  We  find,  indeed,  that  even  when, 
with  the  lapse  of  years,  the  time  arrives  at  which  the  discharge 
naturally  ceases,  its  cessation  is  almost  invariably  followed  by  a 
class  of  symptoms  which  show  that  the  balance  of  the  circulation 
has  been  disturbed,  while  many  months  are  often  needed  to  com- 
plete its  readjustment.  The  liver  now  has  extra  work  to  do  in  the 
de[)uration  of  the  blood,  its  disorders  are  now  more  frequent  than 
at  other  times,  and  though  hemorrhages  not  infrequently  take 
place  which  relieve  the  overtasked  organ,  yet  they  often  pass  the 
limits  of  health,  and  become  themselves  a  fresh  cause  of  suffering, 
or  even  an  occasion  of  danger. 

But  the  very  accidents  to  which  there  is  a  disposition  when 
menstruation  ceases,  may  also  precede  its  occurrence.  If  menstrua- 
tion is  postponed  beyond  the  ordinary  period,  the  system  suffers  in 
the  same  way  as  it  often  does  at  its  cessation.  The  same  double 
duty  is  thrown  on  the  liver,  the  same  disposition  to  its  disorder 
exists,  the  same  tendency  t(3  congestion  of  different  viscera  mani- 
fests itself,  and  frequently  the  same  outbursts  of  hemorrhage  give 
temporary  relief  to  the  congestion,  too  often  also  at  the  expense 
of  the  general  constitutional  vigor.  No  one  who  is  familiar  with 
the  symptoms  that  are  often  associated  with  granular  degeneration 
of  the  kidney  will  be  at  a  loss  to  understand  how  local  plethora 
may  be  associated  with  an  altered  and  impoverished  condition  of 
the  circulating  fluid,  or  will  fail  to  see  how  it  may  sometimes  hap- 
pen that  leeches,  purgative  medicines,  and  active  exercise,  may 
take  that  place  in  the  cure  of  amenorrlioea  which  tonic  remedies, 
ferruginous  preparations,  and  wine  occupy  in  general. 

The  exact  mode  of  applying  these  principles  in  cases  where 
menstruation  has  never  occurred,  must  vary  much  in  different  in- 
stances, though  in  all,  our  chief  endeavor  must  be  directed  to  the 
establishment  of  that  function  through  the  medium  of  the  general 
health,  rather  than  by  means  of  remedies  acting  or  supposed  to 
act,  immediately  on  the  sexual  system.  While,  then,  the  tardy 
occurrence  of  puberty,  just  as  the  tardy  appearance  of  the  teeth  in 
infancy,  furnishes,  when  unattended  by  constitutional  disorder,  no 
indication  for  medical  interference,  the  first  question  that  in  these 
cases  presents  itself  is,  whether  the  symptoms  which  accompany 


ITS    RELATION    TO    CONSTITUTIONAL    DISORDER.  45 

the  amenorrhoea  are  those  of  simple  debility  or  of  that  kind  of 
plethora  which  may  yet  be  associated  with  an  altered  and  deterio- 
rated state  of  the  circulating  fluid. 

But  though  the  decision  of  this  point,  with  a  view  to  the  adop- 
tion of  a  suitable  constitutional  treatment,  claims  our  first  atten- 
tion, there  is  yet  another  which  must  not  be  wholly  lost  sight  of. 
When  its  establishment  is  long  postponed,  the  performance  of  the 
menstrual  function  generally  takes  jilace  painfully,  difficultly,  and 
for  a  long  time  imperfectly,  while,  as  already  mentioned,  it  some- 
times happens  that  the  blood  which  is  not  poured  out  from  the 
uterus  makes  its  escape  through  other  channels ;  such  a  discliarge, 
too,  vicarious  of  menstruation,  sometimes  continues  to  recur  for 
months  together,  not  merely  injuring  the  patient's  health,  but, 
through  the  mysterious  influence  of  habit,  oftering  a  serious  im- 
pediment to  the  proper  performance  of  the  menstrual  function. 
How,  and  why  this  is  so,  I  will  not  pretend  to  explain.  Deficient 
innervation  of  the  sexual  organs  has  been  assumed  to  be  its  cause 
by  some ;  while  others  have  spoken  of  some  special  density  of  the 
uterine  tissue,  preventing  the  ready  outflow  of  blood  ;  or  of  some 
peculiar  thickness  of  the  blood  itself,  which  therefore  could  not 
escape  from  the  pores  that  otherwise  would  give  it  exit.  State- 
ments of  this  kind,  however,  are  but  the  expression  of  very  crude 
hypotheses ;  they  add  nothing  to  our  knowledge,  they  do  not  even 
present  it  to  us  in  a  clearer  form.  What  we  have  to  do  with  is 
the  fact,  that  there  are  certain  periods  more  or  less  well  marked 
in  the  regularity  of  their  return,  when  a  special  disorder  of  the 
nervous  and  vascular  systems,  and  various  forms  of  local  sufl:ering, 
referred  more  or  less  distiiictly  to  the  womb  or  to  the  parts  adja- 
cent, announce  a  sort  of  imperfect  menstrual  eftbrt,  and  that  at 
those  times  various  local  measures  addressed  to  the  uterus  are 
not  infrequently  succeeded  by  the  establishment  of  menstruation, 
though  the  same  measures,  if  had  recourse  to  at  another  time, 
would  be  altogether  unavailing,  or  even  positively  mischievous. 

Treatment  then  resolves  itself  into  what  is  to  be  done  for  the 
improvement  of  the  general  health,  and  what  is  to  be  done  on 
special  occasions  with  a  particular  view  to  the  excitement  of  the 
uterine  function ;  while  it  follows  as  a  necessary  corollary,  that 
when  no  sign  of  menstrual  eftbrt  shows  itself,  then  no  local  meas- 
ures are  indicated.  In  cases  where  general  dcbilit}'  characterizes 
the  patient's  condition,  tonics  in  the  widest  sense  of  the  term  are 
indicated  ;  and  by  them  I  understand  not  merely  tonic  medicines, 
or  preparations  of  iron,  though  they  will  almost  always  be  appro- 
priate, but  the  tonic  influence  of  pure  air,  healthful  pursuits,  and 
exercise  short  of  fatigue.  In  these  cases,  too,  the  one  great  danger 
to  watch  against,  is  that  of  the  supervention  of  phthisis,  and  a 
winter's  residence  at'Torquay  or  Ventnor  is  useful  in  many  in- 
stances, not  only  as  a  means  of  guarding  the  delicate  lungs  from 
the  cold  of  many  inland  ])lacc3,  but  also  because  the  warm  climate 
and  the  sea  air  appear  of  themselves  to  have  a  beneficial  influence 
in  favoring  the  healthy  development  of  the  reproductive  system. 


46  AMENORRHEA, 

The  constipated  state  of  the  bowels,  which  is  so  troublesome  a 
symptom  in  these  cases,  must  be  encountered,  not  by  drastic  pur- 
gatives, but  by  gentler  aperients,  among  which  the  watery  extract 
of  aloes  has  a  well-merited  reputation.  In  some  instances  all 
preparations  of  iron  have  the  effect  of  increasing  the  sluggish 
state  of  the  intestines,  but  this  difficulty  can  in  general  be  got  rid 
of  by  combining  the  iron  with  some  aperient  salt/  At  other  times 
the  delicate  stomach  is  unable  to  bear  the  mildest  ferrugiHOUS 
preparation,  and  in  these  circumstances,  chalybeate  mineral  waters 
will  often  produce  good  effects,  far  beyond  what  might  be  antici- 
pated if  we  regarded  merely  the  quantity  of  the  remedy  they  con- 
tain. The  waters  of  Spa  and  Pyrmont  are  especially  suitable  to 
cases  of  this  description ;  the  former  being  the  milder  and  better 
borne  by  patients  whose  digestive  power  is  very  feeble.  Both 
these  waters  are  very  well  prepared  at  Brighton,  but  patients  of 
this  description  benefit  as  much  by  the  change  of  scene,  the 
healthful  exercise,  the  sort  of  busy  idleness  of  a  watering-place, 
as  by  the  virtues  of  the  spring  to  which  it  owes  its  reputation. 

Even  when  a  state  of  apparent  plethora  predominates,  much 
the  same  kind  of  treatment  is  nevertheless  appropriate;  with  the 
exception,  however,  that  the  preparations  of  iron  are  often  not 
needed  at  all,  while  a  much  more  active  system  of  purgation  is 
generally  indicated.  A  nutritious,  though  not  a  stimulating  diet, 
the  shower-bath,  and  horse  exercise,  are  remedies  of  greater 
power  than  any  which  Apothecaries'  Hall  contains.  The  slug- 
gish state  of  the  liver,  which  constitutes  one  of  the  great  difficul- 
ties that  in  these  cases  we  have  to  contend  with,  must  not  lead  us 
to  the  too  frequent  use  of  mercurials,  especially  of  mercurial  pur- 
gatives. There  are  some  exceptional  cases,  however,  where  other 
remedies  fail  to  excite  a  due  secretion  of  bile,  in  which  the  steady 
employment  of  small  doses  of  bichloride  of  mercury,  persevered 
in  for  several  weeks,  while  a  general  tonic  plan  of  treatment  in 
other  respects  is  continued,  proves  of  most  essential  service. 

But  while  the  general  health  must  be  administered  to  by  means 
sucli  as  I  have  just  described,  the  appearance  of  any  attempt  at 
menstruation,  as  it  indicates  a  different  object  to  be  aimed  at,  so 
calls  for  an  immediate  change  in  the  remedies  to  be  employed. 

The  patient  should  be  kept  quiet,  and  if  there  be  any  consider- 
able suffering,  or  much  disturbance  of  the  circulation,  it  is  desirable 
that  she  should  remain  in  bed,  while  the  hot  hip-bath,  night  and 
morning,  rendered  still  more  stimulating  in  cases  where  the  local 
pain  is  not  very  consideraljle  by  the  addition  of  some  mustard, 
will  often  have  the  effect  of  inducing  the  menstrual  flux.  It  is 
at  this  time  that  the  stimulant  diuretics,  such  as  nitrous  ether. 


R. 


1  (No.  1.) 

' 

Ferri  Sulphatis,     . 
Magnesise  Sulphatis,  .     . 
Acid.  Sulph.  dil.,  .     .     . 
Syrupi  Aurantii,    .     .     . 
Aquae  Carui,  ad,     .     .     . 

.     gr.  ix 

.     ^vi — M.  3J  bis  quotidie, 

PRINCIPLES    OF    TREATMENT.  47 

turpentine,  spirits  of  juniper,  or  the  domestic  emmenagogue  gin, 
sometimes  prove  useful,  and  by  increasing  the  congestion  of  the 
pelvic  viscera,  induce  a  hemorrhage  from  the  uterus,  and  relieve 
the  patient  from  much  sutfering.  "Much  care,  however,  is  needed 
in  the  employment  of  any  of  these  remedies ;  v^'hile  all  violent 
measures,  such  as  the  administration  of  cantharides,  or  of  the  oil 
of  savin  in  large  doses,  or  of  very  powerful  local  stimulants,  such 
as  vaginal  injections  of  liquor  ammonise  mixed  with  milk,  or  the 
introduction  of  nitrate  of  silver  into  the  uterine  cavity,  by  means 
of  Lallemand's  porte-causfique,' ii\)i^ei\v  to  me  to  deserve  reproba- 
tion, as  both  uncertain  and  unsafe.  Electricity,  applied  by  means 
of  the  ordinary  electro-magnetic  apparatus,  one  disk  being  placed 
over  the  pubes  and  the  other  over  the  sacrum,  has  in  some  cases 
been  of  service,  though  its  results,  just  as  when  employed  for  other 
purposes,  appear  to  vary  much,  and  causelessly.  It  was  at  one 
time  anticipated  that  the  ergot  of  rye  would  prove  a  very  valuable 
emmenagogue,  and  indeed  it  was  employed  as  a  popular  means  of 
inducing^menstruation,  long  before  its  introduction  into  obstetric 
practice.  Though  it  has  been  tried,  however,  in  various  forms  of 
powder,  tincture,  infusion,  and  essence,  and  though  experiments 
have  been  made  with  its  essential  principle,  the  ergotine,  yet  its 
peculiar  power  over  the  muscular  activity  of  the  womb  does  not 
appear  to  extend  to  any  other  function  of  the  sexual  organs. 

In  some  instances,  the  pain  experienced  in  the  uterine  region 
with  the  return  of  each  menstrual  period,  is  very  severe  indeed ; 
and  in  such  cases,  while  stimulating  hip-baths  are  out  of  place,  the 
application  of  leeches  to  the  hypogastrium  not  only  relieves  the 
pain,  but  is  often  followed  Ijy  the  occurrence  of  menstruation. 
The  explanation  that  used  to  be  given  of  this  fact,  founded  on  the 
circumstance  that  excessive  congestion  of  a  secretory  organ  often 
puts  a  stop  to  its  activity,  is  scarcely  applicable  now  that  we  know 
the  menstrual  discharge  to  be  a  simple  hemorrhage,  not  a  secretion. 
The  fact,  however,  still  holds  good,  and  the  practice  founded  on  it 
is  worth  remembering. 

I  have  already  referred  to  the  occurrence  of  hemorrhage  from 
various  organs  as  an  occasional  attendant  on  amenorrhoea,  and  have 
suggested  an  explanation  of  its  cause.  ^ledical  writings'  are  full 
of  illustrations  of  this  vicarious  menstruation,  as  it  is  often,  though 
not  quite  correctly,  termed  ;  and  from  them  it  appears  that  the 
hemorrhages  may  occur,  not  merely  from  any  of  the  mucous  sur- 
faces, as  the  stomach,  intestinal  canal,  or  air-passages,  but  also  i'rom 
any  casual  wound,  from  the  surface  of  an  ulcer,  from  the  nipytle, 
from  the  eye ;  in  short,  from  almost  any  conceivable  part  of  the 
body.  Now  it  is  no  part  of  my  object  to  occupy  your  time  with 
a  detail  of  these  mere  medical  wonders ;  but  there  are  several 
things  with  reference  to  them  which  I  wish  you  to  bear  in  mind. 

1  Abundixnt  roferoncos  may  be  found  in  Bricrro  de  Boismont,  De  la  ^f(■llstnto^i<l?J, 
&c.,8vo.,  Tiiris,  1842,  chap,  vi,  p.  374;  and  in  Meissner's  FraueHkrankheUen,S\o., 
Leipsig,  1845,  vol.  ii,  p.  800. 


48  AMENORRHEA, 

The  first  is,  that  after  the  arrival  of  the  period  of  piiherty,  the  non- 
appearance of  the  menses,  or  their  accidental  suppression,  is  likely 
to  be  followed  by  occasional  outbursts  of  hemorrhage,  which  by 
no  means  invariably  correspond  with  any  real  activity  of  the 
sexual  organs,  or  observe  any  distinct  periodicity  of  return.  ISText, 
it  is  to  be  remembered  that  such  discharges,  not  being  genuine 
menstruation,  may  nevertheless  take  place  from  the  uterus,  and 
amenorrhcea  and  a  seeming  menorrhagia  may  alternate  with  each 
other.  Such  hemorrhage,  too,  may  be  extremely  profuse ;  and 
even  within  my  own  observation  it  proved  fatal  to  a  young  lady, 
in  whom  it  succeeded  to  long-continued  suppression  of  the  menses, 
and  whose  uterus  as  far  as  could  be  ascertained  by  examination 
during  life,  was  perfectly  healthy.  Lastly,  the  occurrence  of  this 
hemorrhage  does  not  in  any  material  respect  alter  the  indications 
which  we  are  to  pursue  in  our  treatment,  or  the  means  by  which 
we  must  endeavor  to  accomplish  them.  If  so  profuse  as  to  be. 
hazardous,  the  discharge  must  be  checked  by  appropriate  means; 
but  it  is  to  the  state  of  the  general  health,  and  the  excitement  of 
the  true  menstrual  function,  that  our  chief  care  must  be  directed. 
Habit,  "  the  memory  of  the  body,"'  as  John  Hunter  beautifully 
terms  it,  while  it  plays  a  prominent  part  in  many  of  the  functions 
of  the  animal  economy,  exerts  over  none  so  powerful  an  influence 
as  over  those  of  the  sexual  system  of  the  female.  The  hemorrhage 
vicarious  of  menstruation,  in  its  first  occurrence  perhaps  the  result 
of  mere  accident,  needs  but  to  return  two  or  three  times  for  its 
cure  to  become  diflicult.  After  a  time,  even  though  the  general 
health  may  be  perfectly  good,  and  though  the  ovaries,  as  far  as  we 
can  tell,  perform  their  office  properly,  yet  with  each  return  of  that 
excitement  of  the  circulation  which  should  relieve  itself  through 
the  medium  of  the  uterus,  the  long-established  habit  interferes,  and 
bleeding  takes  place  from  the  lungs  or  from  the  stomach,  or  from 
the  surfiice  of  the  body,  instead  of  from  the  womb. 

But  the  application  of  this  fact  is  wider  than  to  the  mere  deter- 
mining the  prognosis  of  cases  of  hemorrhage  vicarious  of  men- 
struation, though  it  will  at  once  be  obvious  that  they  admit  of 
cure  easily,  or  with  difiiculty,  in  almost  exact  proportion  to  their 
duration.  The  principle  which  it  involves  is  to  be  borne  in  mind 
in  the  management  of  all  the  ailments  that  disturb  the  menstrual 
function.  It  is  not  enough  to  take  precautions  till  menstruation 
has  for  the  first  time  occurred  ;  the  period  for  its  return  should, 
even  in  the  healthiest  girl,  be  watched  for,  and  all  previous  precau- 
tions should  be  once  more  repeated  ;  and  this  should  be  done  again 
and  again,  until  at  length  the  habit  of  regular,  healthy  menstrua- 
tion is  established  ;  and  if  this  be  once  secured,  the  risks  of  its  sub- 
sequent disorder  will  be  very  much  lessened.  Need  I  say  that  this 
truth  bears  with  tenfold  force  on  all  cases  in  which  menstruation 
has  been  tardily,  painfully,  or  difiicultly  accomplished ;  for  in  these 

1   Works,  Palmer's  edition,  vol.  i,  p.  274. 


SUPPRESSION     OF    THE    MENSES.  49 

the  bad  habit  has  to  be  broken  through,  and  a  new  one  formed. 
If  this  be  not  accomplished  during  the  first  few  years  of  woman- 
hood, it  will,  in  all  probability,  never  be  attained. 


LECTURE  I.Y. 

MENSTEUATION  AND  ITS  DISOEDEES. 

Amexorrhcea,  continued — Suppression  of  tlie  Menses — Their  premature  cessation 
— Irregularities  before  final  extinction  tif  function — Various  causes  suspending 
the  menses — Treatment. 

Menorrhagia — Its  two  principal  causes — 1st;  constitutional  ;  2d  local — illustra- 
tions of  each 

Treatment  of  both  classes  of  cases^general  precautions — cases  requiring  antiphlo- 
gistic measures — cases  requiring  tonics  and  astringents — local  remedies — con- 
ditions calling  for  the  plug,  and  for  intra-uterine  injections. 

"We  were  engaged  during  the  last  Lecture  with  the  study  of 
those  cases  in  which  the  menstrual  discharge  has  never  made  its 
appearance.  Another,  and  equally  important  class,  still  remains 
for  consideration,  in  which  menstruation  is  either  interrupted  or 
suppressed. 

It  is  of  course  out  of  the  question  to  attempt  an  examination  of 
all  the  various  circumstances  that  may  give  rise  to  suppression  of 
the  menses,  or  that  may  lead  to  their  permanent  cessation  ;  for  a 
very  large  number  both  of  constitutional  disorders  as  well  as  of 
local  diseases  tend  directly  to  produce  this  result.  Reference  has 
already  been  made  to  the  remarkable  influence  of  phthisis  in  its 
more  advanced  stages  in  leading  to  suppression  of  the  menses,  and 
many  other  cachectic  diseases  exert  a  similar  influence  on  the 
menstrual  function  ;  while  severe  uterine  or  ovarian  inflammation, 
various  forms  of  ovarian  degeneration  or  of  uterine  tumor,  often 
suspend  menstruation  for  months  together,  sometimes  put  a  final 
stop  to  its  occurrence,  many  years  before,  in  the  natural  course  of 
events,  the  sexual  powers  would  lose  their  vigor. 

But  besides  those  cases  in  which  a  definite  reason  can  be  assigned 
for  the  arrest  or  cessation  of  the  menstrual  discharge,  there  are 
others  occasionally  met  with,  in  which  it  disappears  as  the  result 
of  a  [)remature  senescence,  just  as  we  have  observed  it  sometimes 
to  come  on  late  in  life  in  consequence  of  the  tardy  occurrence  of 
puberty.  Thus  while  the  average  duration  of  the  menstrual  func- 
tion is  about  thirty  years,  and  the  age  of  its  cessation  in  the  major- 
ity of  instances,  at  or  a  little  after  forty-five,  it  has  been  known 
to  continue  less  than  ten  years,  and  to  cease  before  the  age  of 
thirty,  and  this,  too,  without  any  peculiarity  in  the  history  of  the 
woman  suggesting  an  adequate  reason  for  so  wide  a  deviation  from 
the  ordinary  rule.'  , 

'  Elaborate  tables  showing  the  duration  of  menstruation,  and  tne  age  at  its 
cessation,  are  to  be  found  in  Bricrre  de  Boismont,  op.  cit.,  pp.  209,  211;  in  Dr. 

4 


50  SUPPRESSION    OF    THE    MENSES. 

To  a  great  extent  the  date  of  the  cessation  of  the  menstrual 
function  is,  I  apprehend,  a  matter  of  indifierence,  and  just  as 
some  persons  of  our  own  sex  retain  sexual  vigor  to  extreme  old 
age,  while  with  others  it  soon  grows  feeble  or  becomes  sluggish, 
so  women  may  long  retain  their  reproductive  powers,  or  may  lose 
them  earl3%  without  their  health  being  better  in  the  one  instance, 
or  less  good  in  the  other. 

Cases,  however,  are  sometimes  met  with,  in  wdiich  a  permanent 
cessation  of  the  menstrual  function  is  associated  with  the  same 
state  of  health,  the  same  condition  of  general  debility,  as  I  have 
already  referred  to  when  speaking  of  the  non-appearance  of  the 
menses,  and  accompanied  with  all  that  collection  of  symptoms 
wdiicli  constitute  chlorosis.  In  these  circumstances  the  same  gen- 
eral treatment,  the  same  chalybeate  remedies  as  are  suited  to  the 
young  girl,  find  their  fit  application  in  the  illness  of  the  matron, 
and  generally  with  the  result  of  improving  the  health  and  repro- 
ducing the  menstruation.  Sometimes,  indeed,  though  the  health 
amends  under  api)ropriate  means,  yet  the  sexual  functions  are 
never  re-established ;  a  result  with  which,  although  far  from  usual, 
it  is  nevertheless  important  that  you  should  be  acquainted. 

But  there  are  many  instances  in  which,  tliough  menstruation  is 
not  finally  arrested,  yet  the  function  is  suspended  for  a  time,  and 
this  accident  is  attended  by  very  various  degrees  of  constitutional 
disorder.  At  the  commencement  of  sexual  activity  and  towards 
its  close,  menstruation  is  often  irregular,  in  the  one  instance  owing 
to  the  organs  not  having  arrived  at  perfection,  in  the  other  owing 
to  the  gradual  loss  of  tiieir  power.  So  frequent,  indeed,  is  this 
irregular  menstruation  as  a  prelude  to  its  final  cessation,  that 
women  have  a  homely  phrase,  the  "  dodging  time,"  by  which  they 
designate  the  period  of  its  occurrence.  I  have  already  told  you 
how  in  the  former  case  you  must  watch  over  the  function,  and 
endeavor  to  bring  on  by  degrees  its  regular  performance.  In  the 
latter,  you  must  confine  your  attention  to  the  general  health,  with- 
out endeavoring  to  re-excite  the  activity  of  organs  which  are  thus 
giving  evidence  of  their  w^aning  powers. 

The  irregular  menstruation  in  the  above  case  is  almost  a  physio- 
logical occurrence;  its  suppression,  in  other  circumstances,  may 
be  due  to  a  great  variety  of  causes ;  it  may  be  owing  to  pregnancy 
— ^to  pregnancy  unsuspected  by  the  person  who  seeks  your  advice. 
I  refer  to  tliis  chiefly  in  order  to  remind  you  that  in  every  case  of 
causeless  suppression  of  the  menses,  just  as  in  every  case  of  ab- 
dominal tumor  in  women,  you  must  bear  in  mind  the  possibility  of 

"Whitehead's  Treatise  on  Sieriliiy  and  Ahoriion,  &c.,  8vo.,  London,  1847,  p.  150; 
and  in  Dr.  Tilt's  work  on  the  Diseases  of  Women,  Bvo.,  2d  ed.,  London,  1853,  pp. 
44  and  46.  My  own  observations  on  the  subject  correspond  with  these  in  showing 
the  differences  to  be  very  wide  indeed  in  this  respect  between  different  and  appar-^ 
ently  equally  healthy  women.  In  my  cases  the  age  at  cessation  of  the  menses  vai'ied 
from  twenty-six  years  in  one  instance,  and  thirty-one  in  another,  to  fifty-eight  in 
the  instance  in  which  it  continued  longest,  while  the  actual  duration  of  tlie  func- 
tion was  omy  eight  years  in  one  person,  and  extended  to  thirty-eight  in  another, 
in  whom  it  lasted  for  the  lonirest  time. 


RULES    FOR    ITS     MANAGEMENT.  51 

pregnancy.  I  do  not  moan  by  this  that  you  are  to  doubt  every 
woman's  word,  or  to  question  every  woman's  chastity,  even  in 
thought,  but  that,  bearing  in  mind  how^  littlg  you  can  know  of 
the  intimate  history  of  many  of  your  patients,  you  must  not  allow" 
your  respect  as  men,  your  gaUantry  as  gentlemen,  to  make  you 
quite  lose  sight  of  what  may  much  import  you  as  physicians. 

lnde[)endently  of  pregnancy,  however,  mere  sexual  intercourse 
not  infrequently  arrests  menstruation  for  a  time,  so  that  in  recently 
married  women,  the  existence  of  pregnancy  is  sometimes  suspected 
for  two  or  three  months,  till,  at  the  end  of  that  time  the  hopes  are 
dissipated  by  the  unwelcome  return  of  the  menstrual  discliarge. 
Habitual  sexual  excesses,  though  they  sometimes  have  an  opposite 
etlect,  and  induce  meuorrhagia,  yet,  in  the  great  majority  of  cases, 
suppress  menstruation  altogether,  or  render  its  return  irregular, 
and  the  quantity  of  discharge  snuill.^ 

Any  sudden  shock,  either  acting  locally  on  the  uterine  organs, 
as  the  application  of  cold  to  the  vulva,  or  through  the  medium 
of  the  general  system,  as  when  a  person  gets  wet-footed,  or  suifers 
during  menstruation  from  exposure  to  wet  or  cold,  wnll  often 
check  the  menstrual  flux.  In  many  of  these  cases,  too,  the  sudden 
arrest  of  the  discharge  is  followed  by  extreme  uterine  pain  and 
tenderness,  by  all  the  symptoms  of  intense  uterine  congestion, 
sometimes,  indeed,  by  actual  uterine  inflammation.  The  mind, 
too,  reacts  upon  the  body,  as  we  see  perpetually  illustrated  in  the 
case  even  of  those  functions  that  might  be  supposed  most  inde- 
pendent of  its  influence,  and  many  instances  might  be  related 
of  sudden  grief,  or  fear,  or  anger,  at  once  arresting  the  menstrual 
discharge. 

But  various  though  its  causes  may  be,  yet  the  treatment  of 
suppression  of  the  menses  rests  for  the  most  part  on  very  simple 
principles,  and  those  the  same  in  almost  all  instances.  Two 
points  require  attention:  first,  to  re-excite  menstruation  at  once, 
if  possible ;  second,  to  provide  for  its  re-establishment  when  the 
proper  period  once  more  comes  round.  If  the  hot  hip  bath,  or  a 
warm  bath,  bed,  and  a  cordial  or  dia[ihoretic,  fail  to  re}>roduce  the 
menses  w'hcn  suddenly  checked  by  cold,  or  b}'  any  other  cause, 
we  nmst  wait  patiently  till  the  next  menstrual  period  comes  round, 
unless  indeed  urgent  symptoms  supervene,  betokening  great  con- 
gestion or  inflammation  of  the  uterus,  and  they  may  require  free 
local  depletion,  or  even  venesection,  and  other  active  measures  to 
♦i  arrest  their  progress. 

With  the  return  of  the  ensuing  menstrual  period,  the  greatest 
care  must  be  taken  to  secure  the  proper  performance  of  the  func- 
tion, by  the  use  of  all  those  means  which  I  mentioned  in  my  last 
lecture,  when  speaking  of  amenorrhoea.  The  importance  of  doing 
this  cannot  be  overrated,  since  many  cases  of  habitual  d^'smenor- 
rhoea,  due  probably  to  a  state  of  chronic  irritation  or  inflammation 

1  See  on  this  subject  the  remarks  of  M.  Parcnt-Diichatelet, — De  U  Prosiituilun 
dans  la  VUle  de  Paris,  vol.  i,  p.  2'J8. 


52  MEItORRHAGTA. 

of  tlie  ovaries,  date  back  to  some  accidental  suppression  of  the 
menses ;  and  the  suffering  has  been  confirmed  by  want  of  due 
care  at  the  return  of  the  next  few  periods. 

It  is  no  part  of  my  phm  to  occupy  your  time  with  passing 
minutely  overground  already  often  trod  before;  and,  therefore,  in 
considering  the  ditibrent  disorders  of  the  menstrual  function,  I 
shall  content  myself  with  pointing  out  to  you  the  grand  principles 
by  which  your  management  of  them  must  be  regulated,  rather 
than  attempt  to  enter  into  detail  concerning  any. 

This  being  so,  we  may  now  pass  from  the  consideration  of  cases 
in  which  the  menses  have  been  scanty,  or  suppressed,  or  have  failed 
to  appear  in  due  time,  to  the  study  of  disorders  of  the  menstrual 
function  of  an  exactly  opposite  character, — to  cases  of  what  is 
termed  menorrhagia,  or  excessive  menstruation. 

This  excess  of  menstruation  may  show  itself  either  in  the  great 
profuseness  of  tlie  flow,  or  in  its  long  duration,  or  in  its  frequent 
return.  It  is,  as  you  will  find  hereafter,  by  no  means  a  matter  of 
indifference,  in  wljich  of  these  respects  the  excessive  menstruation 
first  or  chiefly  shows  itself,  since  from  these  variations  important 
conclusions  may  often  be  drawn,  both  as  to  the  cause  of  the  ail- 
ment and  its  means  of  cure.  It  must,  however,  be  borne  in  mind 
that  menstruation  seldom  continues  long  to  be  excessive  in  one 
respect  alone;  but  if  the  menorrhagia  be  not  speedily  checked, 
the  patient  will  menstruate  not  only  in  greater  quantity,  but  for  a 
longer  time,  and  at  shorter  intervals  than  natural. 

Divisions  and  subdivisions  of  menorrhagia  into  man}'  different 
kinds,  have  been  needlessly  multiplied.  The  only  classification 
that  seems  to  me  of  real  practical  utility,  is  that  which  recognizes 
two  forms,  depending,  either — 

1st,  On  some  cause  seated  in  the  constitution  generally. 

2d,  On  some  affection  of  the  sexual  system. 

This  distinction  should  never  be  lost  sight  of  in  practice,  though 
we  may  seldom  meet  with  instances  in  which  the  actual  line  of 
demarcation  is  drawn  with  the  same  precision  as  we  attempt  to 
observe  in  our  nosologies. 

One  caution  is,  perhaps,  worth  giving,  before  I,say  anything  more 
about  menorrhagia.  It  is,  that  every  excessive  hemorrhage  from 
the  uniinpregnated  uterus,  during  the  years  of  sexual  activity,  is 
not  necessarily  menorrhagia.  Women  themselves  are  apt  so  to 
regard  all  losses  of  blood  during  that  period  of  their  life,  and  practi- 
tioners are  too  often  guilty  of  the  same  oversight.  Menorrhagia 
is  an  excess  of  menstrual  discharge,  an  over  abundant  hemorrhage, 
the  cause  of  which,  in  the  first  instance,  is  that  congestion  of  the 
sexual  organs  which  attends  the  maturation  and  escape  of  an  ovule 
from  the  ovary.  As  1  mentioned  yesterday,  outbursts  of  bleeding 
may  take  place  from  the  wond)  in  some  cases  where  the  menses 
have  been  long  suppressed,  aftbrdiiig  relief  to  the  system,  or  even, 
by  their  excess,  jeopardizing  the  patient's  well-being,  and  this  with 
no  more  real  reference  to  the  function  of  which  menstruation  is 
the  sign,  than  exists  in  a  case  of  hemorrhage  from  the  bowels,  or 


ITS    CAUSES    TWOFOLD.  53 

of  bleeding  from  hemorrlioiJs.  In  the  same  way,  too,  a  patient 
may  bleed  to  death  from  a  cancer  of  the  womb,  or  from  a  polypus, 
or  from  a  fibrous  tumor  of  that  organ,  and  yet  such  hemorrhage 
may  be  no  real  menorrhagia. 

In  tliis  case,  again,  the  distinction  cannot  always  be  drawn,  for 
the  incipient  uterine  disease  may  at  first  have  betrayed  its  exist- 
ence by  the  excessive  congestion  of  the  sexual  system,  and  con- 
sequent abundant  discharge  of  blood  at  a  menstrual  period,  but, 
with  the  advance  of  the  mischief,  bleeding  may  take  place  at  any 
time,  and  independent  of  any  special  occasion  of  uterine  excite- 
ment. I  need  not  sa}' that  a  distinction  does  not  cease  to  be  use- 
ful because  it  is  not  always  practicable  to  make  it. 

But  to  return,^  menorrJiag  ia  was  stated  to  depend  m  some  instances 
on  causes  acting  tJirough  the  medium  of  the  gerieral  system.  Thus, 
for  instance,  some  years  ago  1  saw  a  widow  lady  of  about  forty 
years  of  age,  whose  time  was  divided  between  a  sojourn  in  this 
country  for  two  or  three  months  at  a  time  and  a  residence  during 
the  other  part  of  the  year  in  a  somewhat  damp  situation  in  Ireland. 
Menstruation  was  always  regular  in  the  time  of  its  recurrence  and 
natural  in  quantity  during  her  stay  in  this  countr3%  but  for  some 
two  or  three  years  her  return  to  Ireland  had  been  followed  by  an 
excessivel}^  profuse  discharge  at  each  menstrual  period,  and  by  its 
continuance  for  more  than  twice  as  long  as  usual ;  symptoms  which 
subsided  once  more  after  a  few  weeks'  stay  in  England.  Ilowthe 
change  of  climate  acted  in  this  case  it  is  not  possible  to  say,  though 
illustrations  of  a  somewhat  similar  influence  of  locality  in  modi- 
fying the  uterine  functions  are  for  from  unusual. 

Cases  are  sometimes  met  with  in  which  an  altered  state  of  the 
circulating  fluid,  such  as  even  our  rough  chemistry  can  detect,  co- 
exists with  and  appears  to  be  the  exciting  cause  of  menorrhagia. 
In  cases  of  granular  degeneration  of  the  kidneys,  monorrhagia  is 
far  from  being  of  unconmion  occurrence.    The  altered,  attenuated 

1  Premature  menstruation,  wenfifmrttio  prcpcox,  has  been  classed  by  some  writers 
as  a  form  of  monorrhagia.  I  have  preferred,  liowever,  passing  over  the  sulijeet, 
since  cases  of  precocious  puberty  in  either  sex  concern  the  pliysiologist  rather  than 
the  physician.  Two  remarks  only  suggest  themselves  as  in  ])Iace  here.  Fir.^t,  tiiat 
those  instances  in  which  the  sexual  system  has  been  stimulated  to  premature  ac- 
tivity by  various  injurious  influences  both  physical  and  moral,  are  not  genuine  cases 
of  precocious  puberty;  and  second,  that  neither  are  all  cases  to  be  so  regarded  in 
which  once,  or  oftener,  sanguineous  discharges  have  taken  place  from  the  sexual 
organs  of  infants  and  very  young  female  children. 

Cases  of  genuine  precocious  puberty,  in  which  the  whole  body  ha?  undergone  in 
early  childhood  tlie  various  changes  that  usuallj'  take  place  in  later  years,  and  an- 
nounce the  arrival  of  womanhood,  are  far  less  common  tlian  the  numerous  refer- 
ences to  be  found  to  their  occurrence  in  medical  works  would  at  first  lead  one  to 
inuigine.  A  very  soimd  criticism  on  many  of  the  earlier  cases  is  to  be  found  in 
Naegele,  Ahhaiulbmcfcn,  tfc,  aiiH.Hrm  Gcbieir  (lev  KrauIihrJien  drs  wrihlichen  Gmch- 
lechfen,  8vo.,  Mainz,  1812,  pp.  312-828.  Numerous  references,  though  sonie  of  them 
are  of  doubtful  autlu-nticity,  are  to  be  found  in  Jleissner,  Frntictiknmkheliet) ,  vol. 
ii,  8vo.,  Leipsig,  181"),  p.  723-73!l ;  and  in  Uuseh,  Das  Gesrldrchislvhrn  drs  Weihes, 
vol.  iv,  8vo.,  Lc'ijisig,  18-J3,  ^  243,  pp.  4V.)-4Ctr^;  and,  lastly,  an  interesting  case, 
with  very  sensible  remarks  on  many  jirevious  histories  of  cases  of  pr(>matuie  men- 
struation, will  be  found  in  a  small  tract  of  47  pages,  by  Dr.  Keuter,  Leber  die  Pra- 
cocltdt  der  Menstrtiation,  Bvo.,  Wiesbaden,  1846. 


54  MENORRHAGIA. 

blood  seems  to  escape  more  readily  than  natural  from  the  uterine 
vessels  when  they  are  congested  at  the  return  of  a  menstrual  period ; 
and  three  or  four  cases  of  supposed  disease  of  the  womb  have  come 
under  my  notice,  in  which  the  most  careful  examination  could 
detect  no  local  cause  for  the  profuse  menstruation,  but  in  which 
the  urine  was  discovered  to  be  loaded  with  albumen.  The  hint 
which  this  fixct  suggests  as  to  the  expediency  of  examining  the 
urine,  even  though  no  symptoms  should  seem  to  point  to  the  ex- 
istence of  renal  disease,  is  worth  remembering,  and  the  test-tube 
will  sometimes  help  to  clear  up  an  obscure  case  of  supposed  uter- 
ine ailment.  You  are  not  to  be  specialists,  even  though  chance 
should  lead  you  to  have  most  to  do  with  one  special  class  of  ail- 
ments, but  you  are  to  be  physicians,  and  in  proportion  as  you  learn 
to  estimate  aright  the  influence  of  the  disorders  of  one  part  on  the 
functions  of  another,  will  ^^ou  be  likely  to  prove  good  and  suc- 
cessful practitioners  in  the  treatment  even  of  local  diseases. 

Somewhat  similar  in  their  nature  are  those  cases  of  menorrhngia 
met  with  most  frequently  towards  the  decline  of  sexual  activity, 
in  which,  with  general  disposition  to  plethora  of  tlie  abdominal 
vessels,  a  sluggish  liver,  and  constipated  bowels,  menstruation  is 
sometimes  irregular  in  its  occurrence,  often  anticipates  the  proper 
date  of  its  return,  and  is  often  excessive  in  its  quantity.  Such 
hemorrhages  are  not  of  necessity  menstrual,  tliough  tiny"  usually 
take  place  at  or  near  a  menstrual  period,  the  congestion  of  the 
womb  which  then  exists  favoring  the  occurrence  of  profuse  bleed- 
ing at  that  time  from  the  uterus  rather  than  from  any  other  organ. 

A  tendency  to  hemorrhage  is  a  frequent  attendant  on  many 
conditions  of  debility,  and  we  look,  probably  with  propriety,  on 
some  change  and  deterioration  in  the  circulating  fluid  as  account- 
ing both  for  the  general  feebleness,  and  for  the  local  accident.  In 
women  whose  strength  has  been  exhausted,  or  whose  blood  has 
been  impoverished  by  prolonged  lactation,  the  reappearance  of  tlie 
menses  often  takes  place  with  an  \indue  abundance  of  discharge, 
often  in  such  quantity  as  to  constitute  real  menorrhagia ;  while 
in  many  instances  the  long  duration  of  the  hemorrhage  is  at  least 
as  trying  to  the  patient  as  the  profuseness  with  which  it  flows. 
Here  then  is  another  illustration  of  menorrhagia  from  constitu- 
tional causes. 

These  cases,  indeed,  are  so  frequent  in  their  occurrence,  and 
often  cause  so  much  anxiety,  as  to  claim  a  moment's  special  no- 
tice. A  woman  who  has  reached  the  period  at  which  menstrua- 
tion commonly  ceases,  finds  that,  independent  of  any  cause  to 
which  to  attribute  it,  the  flow  becomes  far  more  profuse  than  was 
its  w^ont.  It  lasts  longer,  is  more  abundant  during  its  flow,  and  often 
returns  more  frequently  than  before ;  but  it  is  unattended  by  pain, 
and  is  not  succeeded  by  purulent  or  mucous  leucorrhoea,  though  a 
sero-sanguineous  discharge  not  infrequently  continues  in  the  in- 
tervals of  menstruation,  or  is  induced  l)y  very  slight  exertion.  The 
absence  of  all  local  discomfort  often  leads  the  patient  to  postpone 
any  treatment  for  months,  under  the  impression  that  the  ailment 


FROIVI    CONSTITUTIONAL    CAUSES.  55 

will  soon  disappear  with  the  spontaneous  cessation  of  menstrua- 
tion, until  at  length  the  daily  increasing  weakness,  the  dyspna^a 
on  slight  exertion,  the  swollen  ankles  and  impaired  digestion,  urge 
her  to  seek  relief  from   symptoms  which  even  then  she  scarcely 
connects  with  the  perpetually-recurring  bleeding.     Such  patients 
come  to  the  out-patient  rooms  of  hospitals,  or  even  present  them- 
selves in  the  consulting-room  of  the  practitioner,  after  long  delays, 
with  the  worn  aspect,  the  pale  and  sallow  countenance  which  at 
once  raise  the  suspicion  that  they  are  suffering  from  malignant 
disease.     This  suspicion,  too,  is  not  infrequently  strengthened  l)y 
the  statement  that  the  discharge  is  occasionally  fcetid — a  condition 
by  no  means  unusual  in  cases  of  long-continued  hemorrhage,  if  the 
blood  is  not  washed  away  from  the  vagina  by  daily  syringing.  In 
every  instance  of  the  causeless  occurrence  of  menorrhagia  in  ad- 
vancing life,  the  probable  existence  of  cancer  must  not  be  lost 
sight  of,  since  to  that,  or  to  the  presence  of  small  fibrous  tumors 
or  polypi,  the  hemorrhage  is  often  due.     In  these  special  cases, 
however,  no  uterine  disease  exists,  though  sometimes,  from  the 
perpetual  afflux  of  blood  towards  it,  tlie  womb  is  increased  in  size. 
Often  the  organ  is  no  larger  than  natural ;  it  is  not  hard,  nor  in  any 
respect  unhealthy,  and  one  feels  at  a  loss  to  account  for  such  grave 
functional  disorder  with  such  complete  absence  of  local  mischief. 
But  though  in  cases  such  as  these  the  sexual  sj'stem  is  not  the 
part  first  in  fault,  yet  no  serious  disorder  of  its  functions  can  take 
place,  still  less  can  recur  frequently,  without  being  accompanied 
by  some  sign  of  uterine  ailment.     A  sense  of  weight  in  the  pelvis, 
a  feeling  of  bearing  down  and  sympathetic  pains  in  the  back,  tell 
that  the  uterus  is  heavier  than  natural,  and  that  its  vessels,  from 
habitual  congestion,  arc  overloaded  with  blood;  while  the  mucous 
discharge  which  persists  in  the  intervals  between  the  menstrual 
periods  is  but  the  effect  of  the  same  condition,  which,  increased  at 
the  time  of  each  ovarian  excitement,  gives  rise  then  to  the  profuse 
outflow  of  blood.     Moreover,  since  the  menstrual  effort  returns 
every  twenty-eight  days,  the  congested  womb  has  not  time  to  re- 
cover itself  between  each  period.  The  blood  has  scarcely  ceased  to 
flow  before  it  is   again   determined  to  the  organ   by  a  renewed 
ovarian  excitement;  and,  its  tissue  being  looser,  its  vessels  more 
dilated  on  each  succeeding  occasion,  allow  more  and  more  readily 
of  the  escape  of  blood,  till  at  length  no  interval  is  left  at  all,  but 
the  flow  goes  on  constantly,  and  menstruation  is  marked  only  by 
a  larger  hemorrhage  than  takes  place  at  other  times.     The  influ- 
ence of  habit,  too,  to  which  I  ret'erred  when  s])eaking  of  amenor- 
rhoea,  is   not  less  marked  in   cases  of  menorrhagia,  tending  to 
per|)etuate  the  evil,  and  to  render  its  removal  difficult,  long  after 
the  cause  to  which  it  was  originally  due  has  ceased  to  be  in  action. 
Some  inferences  api>licable  to  practice  may  be  deduced  from 
what  has  already  been  said. 

1st.  Tiie  importance  of  determining  whether  the  cause  of  the 
menorrhagia  is  to  be  sought  in  the  state  of  the  general  system  or 
of  the  sexual  orirans. 


56  MENORRHAGIA. 

2d.  The  necessity  of  bearing  in  mind  that  even  when  the  ail- 
ment depends  on  a  constitutional  cause,  it  will  yet  be  attended  by 
certain  local  symptoms ;  and  further,  that  the  latter  may  persist 
long  after  the  removal  of  the  former. 

3c7.  It  follows  as  a  corollary  from  the  two  preceding  statements, 
that  it  is  essential  in  every  case  of  long-continued  menorrhagia  to 
determine  by  careful  examination  the  presence  or  absence  of  local 
disease  ;  and  this  the  rather  since  tlie  early  stages  of  organic  uter- 
ine affections  are  not  only  often  accompanied  by  menorrhagia,  but 
also  are  often  unattended  by  any  other  symptom. 

But  there  is  a  second  class  of  cases  in  which  menorrhagia  occurs 
as  the  result  of  some  cause  acting  directly  on  the  sexual  system.  We 
meet  sometimes  with  instances  of  what  seems  like  a  special  sus- 
ceptibility of  the  sexual  system,  in  which  any  sudden  excitement, 
even  though  unconnected  with  the  sexual  functions,  is  followed 
by  hemorrhage  lasting  perhaps  only  for  a  few  hours,  or  for  a  day, 
but  sometimes  continuing  longer,  and  even  passing  into  regular 
menorrhagia;  while  in  all  patients  who  are  liable  to  this  accident, 
menstruation  is  almost  invarial)ly  profuse.  A  similar  effect  is  pro- 
duced by  causes  acting  directly  on  the  sexual  system ;  and  hence, 
while  in  some  cases  we  find  the  unaccustomed  stimulus  of  sexual 
intercourse  lead  to  suppression  of  the  menses,  we  also  observe  it 
in  other  instances  followed  by  their  excess.  Menstruation  in  these 
cases  generally  continues  to  observe  its  proper  periods  of  return, 
but  lasts  on  each  occasion  much  longer  tlian  natural;  M'hile  absti- 
nence from  intercourse  for  a  season,  and  moderate  use  of  it  after- 
wards, are  almost  always  followed  by  the  menstruation  resuming 
its  natural  character.  More  difficult  of  cure,  however,  are  those 
cases  in  which,  from  some  cause  or  other,  the  marriage  is  sterile, 
and  especially  those  in  which,  from  disparity  of  years,  or  from 
constitutional  feebleness  on  the  husband's  part,  the  act  is  but  im- 
perfectly accomplished.  In  these  circumstances  a  sort  of  chronic 
ovarian  irritation  and  chronic  congestion  of  the  woTnb  are  kept 
up,  which  lead  to  a  degree  of  hypertrophy  of  the  uterine  sub- 
stance, and  to  profuse  bleeding  from  its  lining  membrane.  Men- 
orrhagia, too,  not  seldom  occurs  in  prostitutes  from  the  constant 
over-excitement  of  their  sexual  organs,  and  its  cure  is  almost  im- 
possible by  any  means  short  of  the  complete  abandonment  of  their 
habits. 

The  local  causes,  however,  which  may  give  rise  to  menorrhagia 
are  manifold.  Whatever  produces  undue  ovarian  excitement, 
whatever  causes  undue  uterine  congestion,  is  likely  to  occasion  it, 
while  any  circumstance  that  renders  the  womb  larger,  its  texture 
looser,  its  vessels  of  greater  size  tlian  usual,  by  just  so  much  facili- 
tates its  occurrence.  Premature  exertion  after  delivery  is  often 
followed  by  hemorrhage.  If  this  hemorrhage  is  not  speedily 
checked  by  treatment,  and  its  return  guarded  against  by  watchful 
care,  it  soon  assumes  the  menstrual  type,  and  soon  also  becomes 
excessive  in  quantity,  from  the  very  circumstance  that  it  takes 
place  from  an  organ  in  which  the  processes  of  involution  are  as 


FROM    LOCAL    CAUSES.  57 

yet  incomplete,  and  whose  vascular  supply  is  much  more  abundant 
than  it  would  be  if  menstruation  were  delayed  till  the  lapse  of  the 
ordinary  period  after  delivery.  From  a  similar  cause  the  founda- 
tion of  menorrhagia  is  often  laid  in  a  want  of  due  care  at  the  time 
of  the  first  appearance  of  the  menses  after  a  miscarriage  ;  an  occa- 
sion, by-the-bye,  on  which  you  should  not  fail  to  impress  on  your 
patient  the  need  for  what  may  seem  to  be  almost  exaggerated  pre- 
caution. This  condition  of  the  womb,  too,  sometimes  persists  for 
long  periods  after  the  delivery  or  the  miscarriage  to  which  it  was 
originally  due;  or  in  weakly  persons  exists  even  independent  of 
any  appreciable  cause,  and  this  to  so  great  an  extent  that  the 
uterine  sound  may  sometimes  discover  the  length  of  the  utei'ine 
cavity  to  vary  as  much  as  half  an  inch  within  the  course  of  a  single 
week.  This  state  of  relaxation  of  the  tissue,  of  the  womb  likewise 
coexists  very  frequently  with  a  granular,  abraded,  or  ulcerated 
condition  of  the  os  uteri;  local  affections  which,  slight  though 
they  may  seem,  yet  help  to  keep  up  an  habitual  congestion  of  the 
womb,  and  thus  furnish  an  ever  present  occasion  of  menorrhagia. 
Other  causes  still  mio-ht  be  enumerated  as  giving  rise  to  exces- 
sive  menstruation,  such  as  blows  or  other  injuries  inflicted  on  the 
uterus  during  a  menstrual  period.  INIisplacements  of  the  uterus, 
as  retroflexion  or  anteflexion,  are  often  associated  with  it,  and 
various  organic  diseases,  as  polypus,  fibrous  tumor,  or  cancer, 
which  eventually  produce  constant  hemorrhages,  at  first  manifest 
their  existence  in  many  cases  by  an  increased  flow  of  blood  at  the 
ordinary  menstrual  period.  Inflammation  of  the  uterus,  especially, 
I  believe,  of  its  lining  membrane,  has  this  effect  in  very  many  in- 
stances, and  not  only  produces  it  on  a  single  occasion,  but  gives 
rise  to  a  state  in  which  menorrhagia  often  becomes  habitual.  It 
has  also  been  alleged^  that  many  cases  of  obstinate  menorrhagia 
are  dependent  on  a  morbid  state  of  the  uterine  lining  membrane, 
in  which  it  becomes  the  seat  of  minute  polypoid  granulations, 
whose  removal,  by  scraping  away  the  membrane  itself,  is  essential 
to  the  patient's  cure.  There  can,  however,  be  no  doubt  but  that 
the  frequency  of  these  granulations  has  been  greatl}'  overrated ; 
their  existence  is  not  referred  to  by  Pichard  in  his  table  of  ex- 
aminations of  800  uteri  ;^  Rokitansky  does  not  allude  to  them ; 
and  they  did  not  come  under  my  notice  in  any  one  of  seventy 
uteri  which  I  examined  carefully  some  years  since  at  St.  Barthol- 
omew^'s  Hospital.  There  is  no  doubt,  however,  of  their  occasional 
existence,  or  of  their  identity  in  structure  with  the  uterine  mucous 
membrane  itself,^  though,  while  they  have  been  found  in  the  uteri 

'  First  dopcribcd  by  M.  Rdcamior  in  tlio  JnnrnnI  de  C/iirin'ffie  for  1843.  M.  Xonat, 
who  onibrafcs  M.  Kt'caniior's  ojiinioiis,  and  adojtts  his  praolioc,  gives  a  sketoh  of 
tho  litorature  of  tlie  subject  at  p.  193  of  his  Traite  des  Maladies  de  I'  Uterus,  8vo., 
Paris,  18()0. 

'^  Apjiondcd  to  his  book,  Des  abus  de  la  cautei'isaiion,  etc.,  dans  les  maladies  de  la 
mafrice,  Paris,  8vo.,  1840. 

^  Seo  th(>  account  of  their  microscopic  structure  by  M.  Kobin,  in  the  Arc/tives  de 
Medecme,  1847,  vol.  xvii,  p.  411. 


58  MENORRHAGIA. 

of  women  who  had  never  suffered  from  any  form  of  hemorrhage, 
there  is  no  evidence  to  show  that  they  have  any  necessary  con- 
nection with  the  occurrence  of  menorrhagia,  or  that  menorrhagia, 
when  associated  with  them  is  distinguishable  by  any  peculiar 
S3^mptonis.  Tlie  supposition  that  it  is.possible  to  distinguish  tliem 
by  exploring  the  uterine  cavity  with  the  curette  is  ridiculed,  fairly 
enough,  by  M.  Aran/  who  criticizes  the  hazardous  proceedings 
whicli  their  presence  has  been  supposed  to  justify,  and  on  account 
of  which  I  make  this  reference  to  a  pathological  condition  in  it- 
self of  no  great  importance. 

Lastly,  various  affections  of  the  ovaries  are  attended  by  the 
same  result;  and  misplacement  of  those  organs,  their  inflamma- 
tion, and  more  rarely  their  degeneration,  may  be  characterized  by 
abundant  and  over-frequent  menstruation.  Each  of  these  causes 
of  menorrhagia,  however,  as  well  as  all  the  different  affections  of 
the  uterus  itself,  must  engage  our  attention  at  a  future  day,  and 
may  therefore  be  passed  over  now  without  further  notice. 

In  entering  on  the  consideration  of  the  treatment  of  menorrha- 
gia, it  is  almost  superfluous  to  observe  that  this  can  be  by  no 
means  uniform,  but  must  dift'er  almost  as  widely  as  the  various 
causes  to  which  the  excessive  loss  of  blood  is  due. 

In  every  instance,  however,  we  have  to  fulfil  two  indications,  of 
which  sometimes  the  one,  sometimes  the  other  is  the  more  urgent; 
namely,  to  arrest  the  present  hemorrhage,  and  to  remove  the 
cause  on  which  it  depends.  The  ])rinciple  whicli  must  guide  us 
in  endeavoring  to  accomplish  the  latter  are  too  obvious  to  need 
more  than  the  very  briefest  reference.  In  those  patients,  for  in- 
stance, in  whom  the  menorrhagia  is  but  a  sign  and  a  consequence 
of  general  debility,  the  tonic  remedies  and  ferruginous  prepara- 
tions which  tend  to  invigorate  the  health  and  to  improve  the  com- 
position of  the  blood,  will  of  themselves  have  a  most  powerful 
influence  in  checking  the  excessive  discharge  at  the  menstrual 
period.  In  some  of  these  cases,  too,  the  menstruation  is  excessive 
relatively  to  the  patient's  strength,  rather  than  absolutely,  com- 
pared with  the  quantity  of  blood  lost  by  women  in  general  at  a 
menstrual  period.  This  is  so  not  infrequently  with  women  in 
whom  menstruation  appears  during  suckling;  and  in  such  cir- 
cumstances, it  usually  suffices  to  wean  the  child,  and  to  give  some 
simple  tonic,  in  order  to  effect  the  patient's  cure.  Less  amenable 
to  treatment,  of  course,  are  those  cases  in  which  the  alteration  in 
the  circulating  fluid  depends  on  some  deep-seated  cause,  such,  for 
instance,  as  exists  in  cases  of  granular  degeneration  of  the  kid- 
ney ;  though  in  such  it  is  at  once  obvious  that  our  attention  must 

1  In  his  Leqons  sur  les  Maladies  de  V  Uterus,  8vo.,  Paris,  1858,  p.  475.  "What !" 
says  he,  "  do  they  seriously  profess  to  be  able  to  distinguish  bj'  means  of  the  curette 
— -that  is  to  say,  at  the  end  of  a  stem  a  foot  in  length — these  fungosities  which 
measure  in  every  direction  three  or  four  millimeters,  and  which  scarcely  project 
one  or  two  millimeters  beyond  the  surface  of  the  mucous  membrane;  and  this, 
too,  in  spite  of  their  extreme  softness,  and  of  their  continuity,  without  any  distinct 
line  of  demarcation  with  the  healthy  mucous  membrane?" 


INDICATIONS     FOR    TREATMENT.  59 

be  directed  cliiefly  to  something  more  than  the  mere  suppression 
of  the  present  hemorrhage. 

Again,  the  excessive  hemorrhage  that  occurs  in  connection  with 
a  state  of  general  plethora  of  the  abdominal  vessels,  showing  it- 
self in  a  disposition  to  hemorrhoids,  a  sluggish  action  of  the  liver, 
and  a  constipated  state  of  the  bowels  (a  condition  most  frequent 
towards  the  decline  of  the  sexual  powers),  admits  less  of  remedies 
immediately  addressed  to  the  suppression  of  the  bleeding  than  of 
attempts  to  remove  it  l)y  indirect  means.  These  are  the  cases  in 
which  a  carefully  regulated  diet,  whence  all  stimulants  shouhl  be 
banished,  great  attention  to  the  bowels,  with  the  habitual  employ- 
ment of  small  doses  of  saline  aperients,  such  as  the  sulphate  of 
magnesia,  the  potassio- tartrate  of  soda,  or  some  of  the  aperient 
mineral  waters,  as  the  Pullna  water,  for  instance,  continued  for 
w'eeks  together,  will  seldom  fail  to  be  successful.  In  such  cases, 
too,  as  well  as  in  those  of  younger  women,  in  whom,  wnth  a  gen- 
eral state  of  plethora,  and  rather  sluggish  condition  of  the  bowels, 
the  menses  are  with  every  month  becoming  more  and  more  pro- 
fuse, an  active  aperient  taken  the  day  before  their  expected  occur- 
rence often  has  a  most  remarkable  influence  in  restraining  the  ex- 
cessive hemorrhage. 

But  there  are  many  cases  in  which  the  sexual  organs  themselves 
either  are  the  immediate  cause  of  the  menorrhagia,  or  in  Avhich 
changes  that  they  have  undergone  tend  in  great  measure  to  per- 
petuate or  to  aggravate  it.  In  all  the  more  important  forms  of 
uterine  or  ovarian  disease,  the  menorrhagia  is  but  one  out  of  several 
symptoms,  each  of  which  may  claim  our  attention  and  necessitate 
our  interference.  Here,  then,  the  empirical  recourse  to  measures 
for  checking  the  hemorrhage  maj  be  either  out  of  place  or  use- 
less;  and  just  as  the  peculiar  state  of  the  constitution  calls  for 
consideration  in  some  cases,  so  the  precise  character  of  the  local 
ailment  requires  investigation  in  others. 

Not  to  enter,  however,  into  details  which  would  occupy  much 
time  now,  and  must  yet  of  necessit}^  be  incomplete,  I  will  endea- 
vor to  furnish  you  with  some  general  rules  applicable  to  cases  of 
menorrhagia  in  general,  and  then  to  give  you  special  directions 
for  the  management  of  those  in  which  the  amount  of  the  bleeding, 
or  its  persistence,  or  the  state  of  the  patient's  health,  requires  that 
decided  measures  should  be  adopted  for  its  suppression. 

Under  all  varieties  of  condition,  there  are  certain  precautions 
which  tlie  known  liability  of  any  wormian  to  menorrhagia  sluuild 
lead  her  to  adopt  with  the  return  of  each  menstrual  period.  First 
among  the  rules  may  be  mentioned  the  strict  observance  of  the 
horizontal  posture,  from  the  commencement  of  the  discharge,  and 
the  maintenance  of  it  till  the  discharge  ceases.  If  with  this  be 
associated  due  care  that  the  bowels  are  not  constipated,  and  the 
pelvic  viscera  consequently  not  congested  at  the  onset  of  the  pei'iod, 
it  is  surprising  how  many  cases  of  obstinate  menorrhagia  will  be 
relieved  in  a  very  short  time,  and  the  hemorrhage  restrained  within 
proper  limits,  and  this  even  though  all  kinds  of  remedies  had  pre- 


60 


MENORRHAGIA. 


viously  been  long  and  fruitlessly  employed.  To  secure  this  benefit, 
however,  it  is  necessary  that  the  precaution  be  repeated  for  two  or 
three  successive  periods,  and  that  afterwards  a  much  greater  degree 
of  care  should  be  taken  at  the  return  of  each  menstruation  than 
many  women  are  ready  to  observe. 

But  while  these  precautionary  measures  are  alike  applicable  to 
all  forms  of  menorrhagia,  the  management  of  the  case  in  other 
respects  differs  completely,  according  to  whether  the  hemorrhage 
assumes  an  active  or  a  passive  character.  In  the  latter  case,  we 
employ  astringent  remedies  both  generall}"  and  locally,  and  this 
with  a  confident  expectation  of  success  ;  in  the  former,  astringents 
would  be  out  of  place,  and  we  rely  on  antiphlogistic  measures,  of 
greater  or  less  activity,  according  to  the  urgency  of  the  symptoms. 

There  is  one  variety  of  excessive  menstruation,  dependent  on  a 
state  of  intense  uterine  congestion,  if  not  on  actual  inflammation 
of  the  womb,  in  which  the  profuse  loss  of  blood  is  associated  with 
general  febrile  disturbance  of  the  system,  with  a  very  distressing 
sense  of  weight  and  bearing  down,  great  abdominal  and  uterine 
tenderness,  together  with  pains  of  a  periodical  character,  like  those 
of  threatening  miscarriage,  or  of  the  early  stage  of  labor.  These 
symptoms,  to  which  the  name  of  metritis  Jiemorrhagica  has  been 
applied  by  some  continental  writers,  require  both  for  their  relief, 
as  well  as  for  the  suppression  of  the  hemorrhage,  the  abstraction 
of  blood  from  the  arm,  or  tlie  free  application  of  leeches  over  the 
low^er  part  of  the  abdomen  ;  measures  which  are  most  efficacious 
if  taken  just  before  the  occurrence  of  a  menstrual  period,  or  within 
the  first  day  or  two  from  the  commencement  of  the  discharge. 
But  there  are  besides,  other  cases,  in  which,  though  the  symptoms 
are  less  urgent,  yet  any  attempt  directly  to  stop  the  discharge 
would  be  equally  unsuitable.  Such  are  all  those  instances  of 
menorrhagia  that  are  associated  with  a  state  of  general  plethora, 
where  a  flushed  face,  and  a  full  pulse,  and  an  aching  head,  at  the 
commencement  of  the  period,  become  by  degrees  relieved  as  the 
blood  flows,  and  where  the  hemorrhage  seems  to  be  almost  salu- 
tary, were  it  not  that  it  tends  to  become  excessive,  and  tends  also 
to  become  habitual,  persisting  long  after  the  cause  which  first 
occasioned  it  has  ceased.  In  these  cases  a  modified  antiphlogistic 
treatment  must  be  pursued;  small  doses  of  the  sulphate  of  mag- 
nesia wdth  sulphuric  acid,  and  the  tincture  of  henbane,  if  much 
uterine  pain  be  present;  or  the  nitrate  of  potash,  with  tincture  of 
digitalis,  must  be  given,  and  will  scarcely  ever  fail  to  check  the 
bleeding.^ 


1  (No.  2.) 

R.    Mac:nppiiB  Sulphatis,  .  ^iv 

Acid.  Siilph.  diluti,  .  ^:^j 

Tinct.  Hyosciami,     .  .  ^\} 

Aqu?e  Cinnamomi,    .  .  ,^jss 

Aqirne  purje,     .     .     .  .  ^iv 

M.    ft.  mist.,  cujus  sumat  cochl.  ij  am- 
pla  4ta  quaque  hora. 


R. 


(No.  3.) 
Potassaa  Nitratis, 
Tinct.  Digitalis, 
SjTupi  Limonum, 
Aquae  purse, 


.5.1 
ti^xl 

%  vss 


M.    ft.  mist.,  cujus  sumat  cochl.  ij  am- 
pla  4ta.  quaque  hora. 


J 


TREATMENT    OF    THE    ATTACK. 


61 


Cases  presenting;  an  active  cliaracter,  however,  or  calling  for  any 
approach  to  antiphlogistic  measures  in  their  treatment,  are  decid- 
edly exceptional.  Menorrhagia*ls  most  commonly  met  "with  in 
conjunction  with  a  state  of  debility,  and  the  obvious  indication  in 
the  miijority  of  instances  is  to  check  the  bleeding  as  promptly  and 
by  as  direct  means  as  we  can.  With  this  view  it  is  desirable,  in 
all  cases  of  passive  menorrhagia,  particularly  when  the  affection 
has  been  of  long  standing,  to  employ  astringent  remedies,*  such 
as  alum,  gallic  acid,  lead,  or  matico,  from  the  moment  when  the 
discharge  commences,  and  not  to  delay  their  administration  until 
the  hemorrhage  has  become  considerable.  Of  the  four  remedies 
which  I  have  just  mentioned,  the  gallic  acid  and  the  matico  are 
those  in  which  I  have  the  greatest  confidence,  while  I  place  the 
least  reliance  on  the  acetate  of  lead.  I  do  not  know,  however,  of 
any  special  indication  by  which  we  can  judge  beforehand  of  the 
probability  of  one  or  the  other  remedy  proving  specially  applica- 
ble in  any  particular  case,  but  am  accustomed  to  employ  each  in 
succession,  provided  one  should  fail  to  produce  the  desired  effect. 

The  ergot  of  rye  is  employed  by  many  practitioners  in  cases  of 
menorrhagia,  and  this  not  simply  on  account  of  its  action  on  the 
uterus,  but  also  from  its  supposed  styptic  property,  I  used  to 
think  that  it  was  not  possessed  of  any  power  of  arresting  hemor- 
rhage, independent  of  that  which  it  exerts  as  an  excitant  of  the 
muscular  contractions  of  the  womb.  I  hesitate,  now,  however,  to 
express  that  opinion  so  confidently  as  heretofore,  since  I  have  ob- 
served several  instances  in  which  bleeding  has  been  stanched  by 
its  employment  without  any  sensible  uterine  contraction  having 
been  produced.  If  one  were  sure  of  always  obtaining  the  drug 
perfectly  fresh,  I  believe  the  infusion  of  o'j  of  the  ergot  in  .^vi  of 
boiling  water,  to  be  its  most  efficient  preparation,  wliile  the 
greater  number  of  the  essences  and  tinctures  which  are  in  such 
general  use  have  seemed  to  be  almost  equally  inert.  Of  the  es- 
sential principle  of  the  ergot  [ergotine)  I  have  no  experience;  but 
I  believe  that  it  has  not  justified  the  high  expectations  of  the 


1  (No.  4.) 
li.    Aliiminis,  .     .     . 
Sulve  ill 

Aqune  purse,    . 
adde 


3JS 


M. 


Tinct.  Cinnamomi  co. 

Syrupi  Paj)av.  alb.,  ail,    .     ^^^iv 

ft.    mi.st.,    cujiis    .suiiiat   cochl. 


magna  3tia  vel  4ta  quaque  hora. 


(No.  5.) 
R.    Acidi  Gallici,    .     .     . 
Synij)i  siinplici.s,  .     . 
A<j.  (Jiiinamomi,   .     . 
Aqiue  puTie, 
AI.    ft.    mist.,  sumat  cochl. 
4la  quaque  hora. 


gt.  xlviij 
ij   magna 


(No.  G.) 
R.    Plumbi  Acetatis,     ....     _:^ss 
Aceti  dcstillati,       ....     ^ij 

Tinct.  Opii, irjj'xx 

Syriipi  Papav.  alb.,     .     .     .    ^'iv 

Aqu;i3  pura',  ad ^vj 

M.    ft.    mist.,  sumat  cochl.   ij   magna 
4ta  quaque  hora. 


(No.  7.) 
R.    Fol.    Piporis    Angustifolia? 

(Matico), ^ss 

Aqua-  fcTvi'ntis,    .     .     .     .     ^vj 
Macera  jx'r  horas  ij  ct  cola. 

R.    Liipior.  colali, =v^s 

Tinct.  Card,  co.,   ....     ^^iv 
31.    ft.  mist.,  sumat  cyathum  vino.sum 
4ta  quaquc  hori\. 


62  MENORRHAGIA. 

French  physicians  wlio  first  introduced  it  into  practice.  Quite 
recently  my  attention  has  been  called  to  a  new  preparation  of 
ergot  made  by  Mr.  Squire  of  Oxford  Street,  which  I  have  used  in 
doses  of  TTj^xx  to  oss,  every  four  or  every  six  hours,  with  very  good 
results.  In  the  menorrhagia  of  the  climacteric  period,  to  which 
I  referred  a  short  time  ago,  this  preparation  has  seemed  specially- 
useful,  particularly  when  combined  with  the  tincture  of  sesqui- 
chloride  of  iron  ;^  a  combination  wdiich  is  also  very  serviceable  in 
many  instances  of  excessive  menstruation  in  weakly  women. 

Within  the  last  few  years  a  valuable  addition  has  been  made  to 
our  means  of  checking  hemorrhage  from  the  uterus,  by  the  em- 
ployment of  digitalis  in  large  doses.  The  discovery  that  it  was 
possessed  of  marked  h?emostatic  powers,  independent  of  its  indi- 
rect influence  exerted  through  the  circulation,  was  made  almost 
by  accident.  Dr.  Robert  Lee,  of  St.  George's  Hospital,  and  Dr. 
Dickinson,  then  his  obstetric  assistant,  pursued  with  much  ^hli- 
gence  the  observations  first  made  in  the  wards  of  that  institution, 
and  came  to  the  conclusion  that  the  digitalis  arrests  menorrhagia 
by  virtue  of  its  direct  action  on  the  muscular  tissue  of  the  womb. 
In  support  of  this  opinion,  Dr.  Dickinson  mentions,^  that  while 
the  cessation  of  the  hemorrhage  was  by  no  means  constantly  as- 
sociated with  any  change  in  the  frequency  or  the  force  of  the  cir- 
culation, severe  pain  referred  to  the  womb  was  almost  invariably 
experienced  after  the  administration  of  a  large  dose  of  the  infu- 
sion, and  was  speedily  followed  by  the  expulsion  of  a  gush  of  co- 
agulated blood ;  etiects  which  were  commonly  repeated  after  each 
dose.  I  have  given  the  digitalis  in  a  considerable  number  of 
cases,  but  have  never  observed  this  latter  result,  though  I  have 
always  questioned  my  patient  closely  as  to  any  sensation  which 
followed  the  medicine;  and  even  where  its  action  has  been  most 
marked,  I  have  not  found  that  pain  accompanied  the  cessation  of 
bleeding.  At  the  same  time,  its  action  is  by  no  means  propor- 
tionate "to  the  influence  which  it  exerts  on  the  circulation;  for 
though' a  diminution  in  the  frequency  of  the  pulse  was  always  ob- 
servable, yet  those  cases  in  w^hich  the  peculiar  power  of  the  drug 
over  the  heart's  action  was  most  marked  were  by  no  means  the 
instances  in  which  hemorrhage  was  soonest  checked  ;  while  some- 
times, though  it  became  necessary  to  suspend  the  remedy  alto- 
gether, the  bleeding  continued  unabated. 

The  cases  in  which,  in  my  hands,  the  digitalis  proved  most 
useful,  were  cases  of  simple  menorrhagia,  often  of  long  standing ; 
but  either  unaccompanied  by  appreciable  changes  in  the  womb,  or 
at  most  associated  only  with  some  degree  of  hypertrophy.     In 

1  (No.  8.) 

R.    Extracti  Ergotfe  liquidi, ^ij 

Glycerine  purificati, .^iv 

Tinct.  Ferri  Sesquichloridi, 3J 

Syrupi  Zinziberis, ^'iv 

Aquae  purte  ad .^vi 

M.    ft.  mist.,  sumat  cochl.  ij  ampla  6ta  vel  4ta  quaquehora. 
2  Medico- Chirurgical  Transactions,  vol,  xxxix,  p.  1. 


TREATMENT  OF  THE  ATTACK.  63 

many  instances,  too,  this  liypcrtrophy  was  apparently  clue  to  im- 
perfect involution  of  the  uterus  after  delivery  or  abortion,  occur- 
rences which  in  a  good  many  instances  had  been  the  starting-point 
of  the  evil.  In  such  cases  I  have  been  accustomed  to  give  oiv  of 
the  infusion  of  digitalis  every  four  hours,  the  patient  remaining  in 
bed,  and  being  cautioned  at  once  to  discontinue  the  medicine  if  it 
produced  faintness  or  dizziness.  In  most  instances  when  it  proved 
of  benefit,  it  gave  some  earnest  of  this  within  twenty-four  hours 
from  its  first  employment,  while  if  no  effect  were  produced  within 
forty-eight  hours,  I  have  always  discontinued  its  furtlier  adminis- 
tration ;  and  in  no  instance  have  I  continued  its  use  for  longer 
than  between  three  and  four  days. 

The  existence  of  a  very  considerable  degree  of  exhaustion,  and 
the  necessity  for  giving  wine  or  brandy,  do  not  contraindicate  a 
trial  of  digitalis,  though  in  cases  of  great  feebleness  I  generally 
begin  with  only  o'j  instead  of  5iv  of  the  infusion  for  the  first  few 
doses.  The  medicine  has  seemed  to  me  of  little  or  no  utility  in 
cases  where  the  hemorrhage  depends  pn  tumor  or  other  organic 
disease  of  the  womb,  but  in  other  circumstances  I  know  of  no 
means  by  which  we  can  determine  beforehand,  with  an}- consider- 
able certainty,  whether  it  will  prove  successful.  In  sj)ite  of  all 
these  drawbacks,  however,  the  digitalis  is  a  very  valuable  medi- 
cine in  cases  of  menorrhagia ;  in  no  instance  have  I  seen  any 
serious  mischief  result  from  its  employment,  and  in  many  cases 
it  has  certainly  eftected  great  good. 

In  the  great  majority  of  instances  the  observation  of  precautions 
and  the  employment  of  internal  remedies  such  as  I  have  recom- 
mended, suflice  to  restrain  the  loss  of  blood  within  safe  limits  ; 
and  it  then  remains  only  by  judicious  treatment  in  the  interval  to 
guard  against  the  recurrence  of  hemorrhage  at  the  next  menstrual 
period.  But  now  and  then  we  meet  with  cases  in  which  these 
measures  prove  nearly  useless,  or  in  which  the  loss  of  blood  on 
former  occasions  has  already  been  so  considerable,  or  so  often 
repeated,  as  to  render  each  ounce  of  almost  inestimable  importance 
for  the  maintenance  of  the  patient's  health,  possibly  even  for  the 
preservation  of  her  life.  Karely  though  it  happens,  you  must  yet 
bear  in  mind  that  women  sometimes  die  from  loss  of  blood  at  a 
menstrual  period,  and  this  wholly  independent  of  uterine  disease. 
Two  instances  of  this  occurrence  have  come  under  my  notice ;  I 
have  already  referred  to  one  case,  and  the  second  was  even  more 
important,  since  the  person  was  not  only  in  previously  good 
health,  but  an  examination  after  death  ascertained  that  not  only 
her  uterus,  but  every  organ  of  her  body,  was  free  from  any  sign 
of  disease.  She  was  a  young  woman  who,  having  been  sentenced 
to  transportation  for  some  offence  conmiitted  in  Scotland,  was 
sent  by  ship  during  a  storm}'  season  from  Edinburgh  to  London. 
Menstruation  appeared  during  the  voyage,  but  her  exhaustion  was 
not  unnaturally  attributed  in  great  measure  to  sea-sickness.  She 
im})rov^ed  on  being  Umded,  and  though  menstruation  continued 
profuse,  yet  she  made  no  complaint  to  the  officers  of  the  prison. 


64  MENORRHAGIA. 

At  length,  having  fainted  one  day,  she  was  removed  to  the  infirm- 
ary of  the  institution.  Ko  profuse  loss  of  blood  took  place  during 
the  three  or  four  days  that  she  was  there,  but  only  a  slight  draining, 
which  went  on  in  spite  both  of  astringent  remedies  and  of  cold 
applications,  and  under  which  she  sank  exhausted.  A  small 
coagulum  was  found  within  the  uterus,  but  nowhere  was  there 
any  trace  of  disease. 

N^ow  the  bare  possibility  of  any  such  occurrence  happening  is 
reason  enough  for  watching  most  anxiously  every  case  of  very 
profuse  menstruation,  and  for  being  ready  with  appropriate  means 
to  combat  the  symptoms  as  they  increase  in  urgency.  One  of  the 
first  and  most  obvious  means  of  checking  bleeding  from  any  part 
consists  in  the  application  of  cold.  After  the  menses  then  have 
continued  for  two  or  three  days,  provided  they  do  not  show  any 
disposition  to  abate,  the  loins  and  vulva  should  be  sponged  every 
few  hours  with  cold  water,  and  the  patient  should  besides  have  an 
enema  of  about  four  ounces  of  cold  water  night  and  morning.  If 
in  spite  of  these  means,  which,  however,  are  generally  successful, 
the  loss  of  blood  should  still  continue,  wet  cloths  must  be  apdied 
to  the  vulva,  and  astringent  injections  thrown  into  the  vagina, 
for  which  purpose  I  know  of  nothing  better  than  the  infusion  of 
matico. 

If  even  these  means  should  fail,  there  remain  then  but  two  re- 
sources, the  plugging  the  vagina,  and  the  injecting  the  cavity  of 
the  uterus  itself.  The  expediency  of  resorting  to  either  of  these 
measures  must  be  determined  by  a  careful  consideration  of  the 
patient's  general  condition,  quite  as  much  as  by  the  mere  amount 
of  the  hemorrhage.  It  is  not  indeed  in  general  while  blood  is 
flowing  profusely  that  the  necessity  for  their  employment  arises, 
but  at  a  later  period,  when,  with  great  depression  of  the  vital 
powers,  blood  still  drains  away  in  quantities  so  small  as  at  another 
time  would  be  of  no  importance. 

I  need  give  you  no  special  directions  as  to  how  to  plug  the 
vagina,  except  to  remind  you  that  you  will  find  the  speculum  of 
service  in  enabling  you  to  introduce  a  considerable  portion  of  the 
tow,  wool,  or  whatever  material  you  may  employ,  much  more 
speedily,  and  with  much  less  irritation  of  the  vaginal  walls,  than 
would  otherwise  be  practicable.  A  much  better  mode  of  plugging 
the  vagina,  however,  as  well  in  the  unimpregnated  condition,  as 
during  hemorrhage  accompanying  labor,  is  furnished  by  the  simple 
apparatus  first  introduced  into  practice  by  two  German  physicians, 
MM.  Braun  and  Chiari,^  but  which  can  now  be  obtained  of  most 
instrument  makers.  It  consists  of  an  India-rubber  bottle,  to  which 
is  attached  a  metal  tube  furnished  with  a  stopcock,  and  also  a  ring 
to  which  straps  can  be  fastened  for  securing  it  in  its  place  after  it 
has  been  introduced  into  the  vagina.  It  is  introduced  empty,  and 
may  then  be  distended  with  cold  water  to  any  extent,  so  as  to 
form  a  most  efficient  plug,  while  its  withdrawal  requires  nothing 

1  Klinik  der  Geburishulfe,  8vo.,  Erlangen,  1852,  Iste  Lieferung,  p.  125. 


USE    OF     INTRA-UTERINE    INJECTIONS.  65 

more  than  to  turn  the  stopcock  and  let  off  the  water.  I  have 
made  two  alterations  in  it  which  I  think  will  increase  its  useful- 
ness, and  which  consist  in  adapting  its  tube  to  that  of  an  ordinary 
Keid's  syringe,  in  order  that  it  may  be  filled  more  conveniently ; 
and  in  substituting  the  soft  and  yielding  vulcanized  India-rubber 
for  the  hard  caoutchouc  flask  of  the  original  inventors. 

The  injection  of  the  uterine  cavity,  though  a  powerful  means  of 
repressing  hemorrhage,  is  yet  a  proceeding  of  much  hazard,  which 
has  given  rise,  in  many  instances,  to  severe  inflammatory  symp- 
toms. Its  use  should  therefore,  I  conceive,  be  limited  to  cases 
(and  these  are  of  extremely  rare  occurrence),  in  which,  though 
hemorrhage  may  for  the  moment  be  restrained  by  means  of  the 
plug,  it  yet  returns  so  soon  as  that  is  withdrawn,  while  remedies 
fail  to  exercise  any  influence  on  its  flow. 

Such  a  case  was  that  of  a  woman  aged  fifty-one,  who  was  ad- 
mitted into  the  Middlesex  Hospital  under  my  care  on  September 
21st,  1848.  Her  health  had  been  good  till  about  a  j'car  before, 
when  her  menstruation  became  irregular  and  over-frequent,  and 
in  the  previous  April  she  had  an  attack  of  hemorrhage,  for  which 
she  was  treated  with  advantage  in  University  College  Hospital, 
though  bleeding  returned  soon  after  her  discharge  from  that  in- 
stitution, and  had  ever  since  recurred  frequently. 

On  her  admission,  her  appearance  was  extremely  anfemic,  her 
pulse  small,  and  her  voice  almost  inaudible.  She  com})laiiicd  of 
constant  pain  in  the  lumbar  and  right  iliac  regions,  increased  after 
each  attack  of  flooding ;  but  a  vaginal  examination  discovered 
nothing  wrong  about  the  uterus,  except  that  it  was  somewhat  larger 
and  heavier  than  natural.  The  v/hole  class  of  astringent  remedies 
and  astringent  injections  were  employed  with  varying  result  till 
November  16th ;  the  bleeding  sometimes  ceasing  for  a  day  or  two, 
and  then  again  returning.  On  that  day,  however,  the  discharge 
was  so  profuse  that  it  was  considered  necessary  to  introduce  the 
plug.  This  means  arrested  it;  but  at  11  A.  m.  on  November  17th, 
the  plug  having  been  removed  for  six  hours,  hemorrhage  again 
returned,  ai»d  greatly  exhausted  the  patient.  After  being  reintro- 
duced, and  allowed  to  remain  for  twelve  hours,  the  plug  was  once 
more  Avithdrawn,  and  no  return  of  hemorrhage  took  place ;  the 
infusion  of  matico,  which  the  patient  began  to  take  about  this  time, 
appearing  to  restrain  the  bleeding  very  eft'ectually.  During  the 
renuiinder  of  Novendjer,  and  the  first  few  days  of  December,  im- 
provement continued,  but  the  patient  now  again  experienced  fre- 
quent returns  of  hemorrhage,  either  in  the  form  of  a  draining 
away  of  a  pale  sanguineous  fluid,  or  in  that  of  frequent  sudden 
gushes  of  profuse  bleeding.  Previous  to  any  profuse  gush,  she 
complained  of  pain  in  one  or  other  iliac  region,  most  frequently 
the  right.  Remedies  seemed  to  have  completely  lost  all  influence, 
and  on  December  18tli,  though  the  hemorrli;ige  was  not  at  that 
moment  very  profuse,  yet  the  patient  was  reduced  by  it  to  a  state 
of  extreme  exhaustion,  her  pulse  was  scarcely  percei)tible,  her  voice 
a  mere  whisper,  and  her  stomach  rejected  everything.     The  os 

5 


66  MENORRHAGIA. 

uteri  was  open  wide  enough  to  admit  the  finger  as  far  as  the  first 
joint,  but  its  tissue  seemed  quite  healthy,  and  under  the  specuhim 
the  appearance  of  the  os  was  perfectly  naturah  About  three 
drachms  of  a  mixture  of  a  scruple  of  gallic  acid  in  an  ounce  of 
water  were  now  thrown  into  the  uterine  cavity,  and  no  consider- 
able pain  was  excited  by  the  injection.  At  the  same  time  pure 
brandy  was  given  to  rally  the  patient's  powers,  and  as  soon  as  her 
stomach  could  bear  it,  the  infusion  of  ergot  of  rye  was  adminis- 
tered every  few  hours.  It  is  needless  to  detail  the  daily  treatment 
adopted  from  this  period,  for  convalescence,  as  might  be  antici- 
pated, was  tardy.  From  the  time  of  the  injection  of  the  uterus, 
however,  the  hemorrhage  completely  ceased,  its  place  being  taken 
by  a  puriform  discharge  just  tinged  with  blood,  and  no  hemor- 
rhage reappeared  until  the  26th  of  January,  when  it  was  neither 
excessive  in  quantity  nor  of  long  duration.  At  intervals  of  rather 
less  than  a  month  hemorrhage  recurred,  though  it  was  always 
readily  controlled  by  treatment,  and  on  April  10th  she  was  dis- 
charged from  the  hospital,  well,  though  still  rather  weak  ;  her  life 
having  to  all  appearance  been  saved,  when  in  most  imminent 
peril,  by  the  injection  into  the  uterine  cavity. 

I  have  no  experience  of  the  employment  of  turpentine  as  an 
injection  into  the  uterine  cavity  in  cases  of  uncontrollable  hemor- 
rhage. I  should  fear  to  employ  such  an  agent,  which,  indeed,  has 
been  followed,'  when  thus  used,  by  violent  inflammation  of  the 
womb.  The  infusion  of  matico,  a  solution  of  gallic  acid,  or  a  mix- 
ture of  one  part  of  the  muriatcd  tincture  of  iron  and  nine  parts  of 
water,  would  appear  to  me  to  be  safer  remedies. 

Xhe  distressing  symptoms  which  have  not  seldom  followed  the 
employment  of  intra-uterine  injections  are  probably,  in  most  in- 
stances, due  to  the  irritation  of  the  mucous  membrane  itself,  and 
are  by  no  means  invariably  dependent  on  the  passage  of  the  fluid 
into  the  peritoneal  cavity.  There  can  be  no  doubt,  indeed,  but 
that  this  accident  has  occasionally  happened,  but  recent  observa- 
tions and  experiments  seem  to  prove  that  the  chances  are  consider- 
ably against  its  occurrence.  The  precautions  suggested  by  M. 
Ouyon,^  who  has  most  recently  investigated  the  subject,  ought, 
however,  never  to  be  omitted.  These  consist  in  introducing  the 
tube  of  any  syringe  which  may  be  employed  only  a  very  few  lines 
within  the  cervical  canal  in  those  cases  in  which  it  is  wished  to 
limit  the  action  of  the  injection  to  the  neck  of  the  uterus.  When- 
ever it  is  intended  to  throw  fluid  into  the  cavity  of  the  womb 
itself,  the  tube  of  any  syringe  must  be  very  narrow,  so  as  to  admit 
of  the  ready  and  immediate  outflow  of  the  fluid;  the  quantity  in- 
jected must  be  extremely  small,  not  above  fort}^  minims  in  the 
case  of  a  person  who  has  never  been  pregnant,  and  a  little  more 
than  a  drachm  into  the  uterus  of  a  woman  who  has  borne  children. 

1  See  a  case  related  in  Ash  well 's  Treatise  on  Diseases  of  Woinen,  8vo. ,  1 843,  p.  1 55. 
*  Etude  sur  les  Cavites  de  V  Uterus  d  V Etat  de  Vacuite,  in  Journal  de  I'hysiologie, 
Tol.  ii,  1859.     See  p.  413. 


PROPOSED  SCRAPING  OF  UTERUS.  67 

Lastly,  I  wisli  to  add  a  word  of  caution  with  reference  to  the 
scraping  of  the  mucous  membrane  of  the  uterus,  with  a  gouge,  as 
a  means  of  arresting  menorrhagia — a  proceeding  which,  while 
falling  into  disuse  in  France,  has  recently  met  with  strong  advo- 
cates in  this  country.^  I  own  that  I  have  not  practised  it  myself, 
but  that  my  conclusions  with  reference  to  it  are  drawn  partly 
from  the  admissions  of  its  advocates,  partly  from  the  arguments 
of  its  opponents.  I  reproduce,  therefore,  as  perfectly  conclusive 
to  my  own  mind,  the  observations  of  M.  Aran  on  the  subject- — a 
physician  whose  premature  death  has  been  a  loss  not  only  to  his 
own  friends  and  his  own  country,  but  has  been  felt  by  all  who 
are  engaged  in  the  cultivation  of  medicine,  and  who  can  ill  afford 
to  lose  thus  early  one  of  the  most  diligent,  most  acute,  and  most 
honest  of  their  fellow-laborers.  "I  am  surprised,"  says  he,  in 
words  which  I  am  merely  condensing,  "that  the  advocates  of  this 
operation  have  not  made  a  few  experiments  on  the  dead  8u1)ject. 
They  would  then  have  found  that  the  curette  does  not  act  equally 
on  all  points  of  the  uterine  cavity;  that  while  it  easily  reaches  the 
posterior  and  lateral  walls  of  the  organ,  it  can  scarcely  be  applied 
at  all  to  the  anterior  surface  and  the  vicinity  of  the  tubes,  though 
these  are  the  very  situations  where  the  vegetations  are  most  fre- 
quently met  with.  They  would  farther  have  found  that  these 
little  bodies,  varying  in  size  from  a  millet-seed  to  a  pea,  can  be 
scraped  out  of  the  cavity  of  any  uterus,  since  they  are  neither  more 
nor  less  than  little  bits  of  epithelium  frayed  from  the  mucous 
membrane  by  the  action  of  the  instrument.  It  is  not,  indeed,  that 
I  absolutely  deny  that  in  some  few  cases*genuine  vegetations  may 
have  been  detached  by  its  means,  bat  what  I  maintain  is,  that  that 
is  nothing  more  than  a  lucky  accident,  and  that  one  cannot  raise 
to  the  rank  of  a  regular  operation  a  proceeding  which  is  nothing 
more  than  a  sort  of  blindfold  shooting  at  a  mark." 

M.  Aran  then  suggests,  in  explanation  of  the  success  which  has 
sometimes  followed  this  mode  of  treatment,  the  probability  that  it 
acts,  as  to  such  proceedings  as  the  cauterization  of  the  interior  of 
the  uterus,  by  exciting  the  womb  to  very  vigorous  contractions  ; 
while  further  it  is  possible  that  some  modiiication  may  also  be 
produced  by  the  inflammatory  action  induced  in  the  mucous 
membrane.  lie  concludes  by  stating  that  three  instances  of 
death  have  come  to  his  own  knowledge  where  the  operation  was 
resorted  to  by  some  of  its  most  skilful  advocates  ;  that  he  believes 
similar  occurrences  have  come  under  the  observation  of  other 
practitioners  ;  and  that  he  retains  a  painful  recollection  of  "  the 
numerous  instances  of  perforation  of  the  uterine  cavity,  some  of 
them  followed  by  death,  which  M.  lidcamier  communicated  to  the 
Academy  of  Medicine  a  few  years  since,  and  which  produced  a 
general  impression  of  surprise  and  regret." 

It  is  almost  superfluous  to  add  two  other  remarks,  in  which  my 

•  Dr.  Routh  in  Obstetrical  Transactions^  vol.  ii,  p.  117. 
2  Op.  cit.,  vol.  i,  pp.  472-481. 


68  NEURALGIC    DYSMENORRHCEA. 

own  observation  entirely  coincides  with  that  of  M.  Aran — namely, 
that,  in  the  first  place,  in  very  few  of  the  published  cases  in  which 
the  scraping  of  the  uterus  was  had  recourse  to,  had  a  suitable 
treatment  been  adopted  l)eforehand  ;  and,  in  the  next  place,  these 
hemorrhages  admit  of  being  put  a  stop  to  by  other  and  less 
hazardous  proceedings. 


LECTURE    V. 

MENSTKUATION,  AND  ITS  DISOEDEES. 

Dysmenoerhoea — its  three  varieties — neuralgic,  congestive,  mechanical.  Symp- 
toms of  neuralgic  form  ;  of  congestive  form,  sometiinos  attended  with  expulsion 
of  a  membrane.  Eelation  of  congestive  dysmenorrlionx  to  rheumatic,  or  gouty 
diathesis.  Mechanical  dysmenorrhoea,  from  contraction  of  cervix  uteri,  a  rare 
occurrence. 

Treatment  of  the  neuralgic  forin  ;  various  sedatives,  and  their  comparative  results 
— of  the  congestive  form  ;  depiction,  and  how  to  apply  leeches — treatment  of 
the  rheumatic  variety — of  the  mechanical  form  ;  cautions  with  reference  to  its 
treatment. 

I  FEAR  you  may  think  that  I  am  uttering  a  very  superfluous 
truism  when  I  remind  you  that  almost  every  function  of  the  body, 
if  ill  performed,  is  performed  with  an  unusual  amount  of  pain. 
The  feeble  stomach  is  pained  by  the  presence  of  the  food  which  it 
is  unable  to  digest;  the  eye  whose  vision  is  imperfect,  is  pained 
by  the  efibrt  to  decipher  even  the  most  legible  characters ;  and 
the  head  of  the  convalescent  aches  on  the  first  attempt  to  resume 
his  ordinary  mental  occupations. 

Just  so  the  menstrual  function  when  deviating  from  its  most 
exact  performance,  either  in  excess  or  in  defect,  is  almost  always 
attended  by  suffering  far  exceeding  that  discomfort  by  which,  in 
the  case  of  health}^  women,  it  is  usuall}^  accompanied.  Amenor- 
rhoea  and  menorrhagia  are  both  almost  invariably  associated  with 
suffering,  and  in  the  case  of  the  most  various  disorders  of  the 
sexual  organs,  an  undue  amount  of  pain  at  each  menstrual  period 
is  a  symptom  scarcely  ever  absent.  But,  besides  these  instances 
in  which  the  pain  is  but  one  among  many  ills  for  which  the 
patient  seeks  our  aid  (and  probably  even  in  her  estimate  by  no 
means  the  gravest),  there  are  other  cases  where  the  suflering  of 
menstruation  is  so  intense  in  its  severity,  or  so  importunate  from 
its  continuance,  as  to  constitute  a  distinct  affection,  and  to  claim 
a  place  in  our  nosologies  as  dysmenorrhoea. 

It  has  been  customary  to  recognize  three  different  varieties  of 
this  dysmenorrhoea,  or  painful  menstruation  ;  and  the  distinction 
of  neuralgic,  congestive,  and  mechanical  dysmenorrhoea,  terms 
which  interpret  themselves,  seems  to  me  to  rest  on  good  grounds, 
and  to  merit  being  generally  adopted. 


NEURALGIC    DYSMENORRHCEA.  69 

There  are  some  instances  in  which  pain  alone,  unattended  hy 
any  other  symptom,  is  the  only  important  respect  in  wliich  men- 
struation differs  from  a  healthy  state.  This  neuraJgic  dysmenor- 
rhoea  occurs  most  frequently,  and  in  its  simplest  form,  in  young 
women  whose  sexual  system  has  not  been  developed  till  a  com- 
paratively late  period,  and  who  have  not  begun  to  menstruate  till 
a  year  or  two  after  the  average  date.  The  pain,  in  such  cases, 
precedes  menstruation  for  a  day  or  two,  generall}^  reaches  its 
greatest  intensity  in  the  course  of  the  first  thirty-six  hours  of  the 
catamenial  flow,  being  sometimes  so  intense  that  the  patient 
writhes  on  the  floor  in  agony,  and  then  by  degrees  subsides,  though 
it  does  not  cease  entirely  till  the  period  is  over.  Though  severest 
in  the  uterine  and  pelvic  regions,  the  pain  is  not  in  general  limited 
to  those  situations,  but  is  experienced  also  in  the  back  and  loins, 
is  referred  to  either  groin,  or  rather  to  each  ovarian  region,  and 
shoots  down  the  inside  of  the  thighs.  The  pain,  too,  is  aggravated 
at  intervals,  and  becomes  paroxysmal,  like  that  of  colic  or  of 
labor,  while  the  whole  abdominal  surface  is  so  tender  as  scarcely 
to  bear  the  slightest  touch.  In  addition  to  these  pains,  all  radiat- 
ing more  or  less  obviously  from  the  sexual  organs,  there  is  often 
much  suftering  in  other  parts.  Intense  headaclje  is  very  frequent, 
often  confined  to  one  side  of  the  head,  or  presenting  the  well- 
known  characters  of  clavus  hystericus;  or,  in  other  cases,  the 
stomach  is  disordered,  and  the  patient  distressed  by  constant 
nausea  or  frequent  vomiting.  In  many  instances,  various  other 
hysterical  symptoms  manifest  themselves,  often,  indeed,  with 
peculiar  intensity,  and  I  knew  a  patient  in  whom  an  attack  of  hys- 
terical mania  ushered  in  on  more  than  one  occasion  a  menstrual 
period.  This  neuralgic  dj-smenorrhoea,  however,  is  by  no  means 
invariably  associated  with  an  hysterical  temperament,  and  patients 
who  suffer  most  intensely  during  menstruation,  sometimes  mani- 
fest no  symptom  of  hysteria,  but,  on  the  contrary,  are  remarkable 
for  quiet  self  possession  and  well-regulated  minds. 

In  some  instances,  it  seems  as  if  the  disorder  of  the  nerves  ex- 
tended to  the  whole  system,  while  in  others  it  is  limited  to  those 
which  supply  the  sexual  organs,  and  is  then  usually  of  shorter 
duration  on  each  occasion,  though  not  by  an}'  means  of  necessity 
slighter  in  the  suffering  which  attends  it  tlian  when  the  sympa- 
thies which  it  awakens  are  more  extensive.  Even  when  pain 
has  altogether  subsided  after  the  cessation  of  a  menstrual  period, 
any  excitement  of  the  sexual  system  will,  in  very  many  instances, 
suffice  to  reproduce  suffering.  In  married  women  affected  with 
this  form  of  dysmenorrhoea,  sexual  congress  is  almost  invariably 
extremely  painful,  while  pregnancy  is  attended  by  more  than  the 
ordinary  degree  of  local  discomfort,  and  the  pain  of  parturition 
amounts  to  intolerable  anguish. 

I  have  referred  to  this  neuralgic  dysmenorrhoea  as  occurring  in 
its  simplest  form  in  young  women  in  whom  there  was  a  tardy, 
and  perhaps  an  incomplete  development  of  the  sexual  system.  It 
is,  however,  by  no  means  limited  to  such  persons,  but  sometimes 


70  CONGESTIVE    DYSMENORRHCEA, 

comes  on  after  years  of  healthy  and  comparatively  painless  men- 
struation. I  have  known  menstruation  become  painful  during 
convalescence  from  some  serious  illness  wholly  unconnected  with 
the  sexual  functions,  and  continue  so  loug  after  the  patient  had, 
in  other  respects,  regained  her  usual  health.  In  other  cases,  the 
sudden  suppression  of  the  menses  by  cold,  or;  some  other  acci- 
dental cause,  is  succeeded  by  obstinate  d3'smenorrhoea ;  and  this 
although  no  obvious  uterine  ailment  had  followed  the  accident. 
At  other  times,  inflammation  of  the  uterus,  after  delivery  or  mis- 
carriage, is  followed  by  painful  menstruation,  which  persists  long 
after  every  trace  of  inflammation  or  of  its  consequences  has  com- 
pletely disappeared. 

But  there  is  another  form  of  dysmenorrhoea  which  has  been 
termed  th^e  congestive,  from  the  peculiar  circumstances  that  attend 
it.  Unlike  the  purely  neuralgic  variety,  it  is  less  frequent  at  the 
commencement  of  sexual  vigor  than  as  an  acquired  condition  at  a 
later  period  of  life.  A  sense  of  weight  about  the  pelvis,  and  a 
tendency  to  hemorrhoidal  afl'ections,  generally  exist  in  the  interval 
between  the  menstrual  periods;  and  tliese  symptoms  increase  con- 
siderably a  few  days  before  the  discharge  comes  on.  During  the 
first  twenty-four  or  thirty-six  hours  of  each  menstruation,  the  dis- 
charge in  general  is  but  scanty,  and  the  pain  is  very  severe.  At 
the  end  of  this  time,  however,  sometimes  even  sooner,  the  hemor- 
rhage often  becomes  abundant;  and  as  the  blood  flows  the  pain 
^abates,  and  then  ceases  altogether.  The  congested  womb  ached 
till  nature  bled  it,  just  as  the  head  aches,  when  the  brain  is  con- 
gested, till  the  cupping-glasses  or  the  leeches  have  relieved  the 
overloaded  cerebral  vessels.  Sometimes  in  these  cases  the  men- 
strual flux  at  no  time  becomes  abundant,  and  consequently  the 
relief  which  nature  gives  is  very  partial.  When  this  is  so,  the 
womb  continues  to  ache  and  throb  during  the  whole  of  the  men- 
strual period,  and  is  left  afterwards  tender  and  painful.  When 
this  is  not  the  case,  however,  the  end  of  the  menstrual  period 
generally  leaves  the  patient  in  a  state  of  comparative  comfort.  For 
the  next  week  or  ten  days  she  continues  to  enjoy  a  comparative 
immunity  from  suflering ;  but  then  the  symptoms  gradually  re- 
turn, and  reach  their  climax  of  severity  with  the  commencement 
of  the  next  menstruation. 

In  some  instances  of  this  form  of  dysmenorrhoea,  not  only  is  the 
amount  of  blood  lost  at  a  menstrual  period  insuiiicient  to  relieve 
the  congested  womb,  but  it  is  absolutely  as  well  as  relatively  scanty. 
In  some  of  the  cases  the  discharge  having  continued  for  a  few 
hours,  ceases,  and  then  comes  on  again ;  while,  though  scanty,  it 
is  intermixed  with  small  coagula,  owing,  probably,  to  the  blood 
having  been  poured  out  so  slowly  as  to  allow  of  its  coagulating 
within  the  uterine  cavitj';  an  occurrence  prevented  during  healthy 
menstruation  by  its  comparatively  rapid  flow  into  the  vagina, 
where  its  fibrine  is  at  once  dissolved  by  the  acid  secretion  of  that 
canal,  and  its  coagulating  property  destroyed. 

In  others  of  these  cases  we  find  intermingled  with  the  menstrual 


WITH     EXPULSION    OF    MEMBRANE.  71 

discharge,  shreds,  or  strips,  or  distinct  laminse  of  menihrane,  or 
even  a  small,  membranous  sac,  which  is  seen,  on  careful  exami- 
nation, to  form  a  com[)lete  cast  of  the  uterine  cavity.  This  occur- 
rence sometimes  takes  place  only  once,  but  oftener  it  reappears 
during  a  long  succession  of  menstrual  periods.  The  discharge  of 
the  membrane  is  generally  associated  with  very  considerable 
aggravation  of  the  patient's  suffering;  sometimes  with  distinct 
periodical  pains,  like  those  of  abortion;  and  when  to  them  pro- 
fuse hemorrhage  is  superadded,  an  occurrence  which  is  frequent, 
though  not  invariable,  unfounded  suspicions  have  in  some  in- 
stajices  been  entertained  with  reference  to  the  chastity  of  women 
wlio  have  had  the  misfortune  to  present  this  combination  of 
symptoms. 

In  the  ignorance  which  till  lately  prevailed  with  reference  to  the 
real  structure  of  the  uterine  lining  membrane,  it  was  customary 
to  speak  of  the  dysmenorrhceal  membrane  as  the  product  of  in- 
flammation, or  of  some  [irocess  akin  to  it.  We  know,  however, 
that  during  menstruation  the  epithelium  of  the  uterine  cavity  is 
thrown  oft' in  greater  or  less  abundance  ;  while  an  examination  of 
the  membrane  suffices  to  show  that  what  has  occurred  in  its  for- 
mation and  detachment  is  merely  an  exaggeration  of  the  process 
which  to  a  less  degree  takes  place  at  every  menstrual  period.^ 
The  membrane  is  smooth  on  one  surfice,  rough,  almost  villous, 
on  the  other,  and  presents  the  remains  of  numerous  dilated  uterine 
glands  ;  characters  that  prove  it  to  be  the  analogue  of  that  decidua 
which,  under  the  physiological  stimulus  of  conception,  passes 
through  a  more  complete  development  to  serve  important  pur- 
poses.^ 

1  scarcely  need  say  that  it  is  not  a  matter  of  indiff'erence  in  a 
practical  point  of  view,  whether  or  no,  you  entertain  correct  opin- 
ions with  reference  to  the  structure  of  this  membrane.  To  regard 
it  as  a  layer  of  plastic  lymph  similar  to  that  which  is  poured  out 
in  croup,  at  once  suggests  the  employment  for  its  removal  of  active 
antiphlogistic  measures,  such  as  experience  would  by  no  means 
justifv.  Reasoning,  however,  even  independent  of  the  actual  ob- 
servation to  which  I  have  appealed,  Avould  suffice  to  show  the 
fallacy  of  this  opinion.  It  is  utterly  inconceivable  that  a  mucous 
membrane  so  inflamed  as  to  become  the  seat  of  deposits  of  lymph 
should  in  a  few  days  return  to  a  perfectly  healthy  condition,  and 
yet  periodically  undergo  the  same  intense  inflammation,  issuing 

'  This  opinion  a?  to  the  identity  in  character  of  dysmenorriioeal  membrane  and 
decidua  is  now  almost  iinivcrjally  entertained,  both  in  this  country  and  on  the 
continent.  In  this  country  the  first  to  assert  this  identity  were,  I  believe.  Dr. 
Oldham,  in  Med.  G«z.,  April  IG,  1846,  and  Dr.  Simpson,  in  Edin.  Monthly  Journal, 
Sept.  184G. 

2  All  membranes,  however,  expelled  durincj  painful  menstruation  arc  not  uterine 
products.  Dr.  A.  Farre,  in  a  paper  published  in  Beale's  Arc/iivcs  of  Medicine,  No. 
II,  1858,  shows  that  occasionally  the  mucous  membrane  of  the  vaijina  exfoliates  in 
layers  forming  even  a  complete  cast  of  the  canal.  Their  expulsion  was  accompanied 
in  each  of  the  cases  related  by  much  sulfering,  though,  as  might  be  expected,  re- 
ferred more  to  the  vagina  than  to  the  uterus. 


72  CONGESTIVE    DYSMENORRHCEA. 

in  the  same  deposit;  and  this  with  no  serious  injury  to  its  func- 
tions and  no  permanent  change  of  its  structure. 

Allied  to  this  congestive  dysmenorrhoea,  are  cases  of  painful 
menstruation  dependent  on  constitutional  causes,  especiall}^  on  the 
gouty  or  rheumatic  diathesis  ;  though  I  cannot  pretend  to  say  why 
in  women  this  peculiar  ailment  should  result  fi-om  it  so  much  more 
frequently  than  the  ordinary  forms  of  those  disorders  with  which 
we  are  familiar  in  the  male  sex.  Such  cases,  however,  are  by  no 
means  rare  in  any  class  of  society ;  and  wherever  they  occur,  they 
are  chronic  in  their  course  and  difficult  of  cure.'  A  casual  attack 
of  cold  is  in  some  instances  referred  to  as  the  occasion  of  the  pa- 
tient's illness,  while  in  other  cases  the  ailment  comes  on  by  degrees, 
and  with  no  definite  exciting  cause.  Menstruation  begins  to  be 
more  painful  than  was  its  wont,  often  more  scanty ;  an  unusual 
degree  of  constitutional  disturbance  attends  each  period;  the  pulse 
at  those  times  is  very  frequent,  the  skin  hot  though  perspiring, 
and  lithates  abound  in  the  urine.  In  the  intervals,  profuse  leu- 
corrhoeal  discharges  take  place;  the  pain,  though  less  intense,  is 
yet  severe,  and  is  aggravated  by  trifling  causes,  or  without  any 
obvious  reason.  The  pain  at  one  time  is  most  severe  in  the  back, 
at  another  is  referred  to  one  or  other  iliac  region,  shooting  down 
the  legs  in  the  course  of  the  crural  nerve,  or,  like  sciatica,  affect- 
ing the  back  of  the  thighs  ;  while  occasionally,  in  addition  to  these 
abiding  discomforts,  the  patient  is  kept  in  bed  for  a  day  or  two  at 
a  time  by  slight  feverish  attacks,  accompanied  by  wandering  pains 
in  the  limbs,  though  seldom  attended  by  inflammation  and  swell- 
ing of  any  of  the  joints. 

The  seat  of  the  pain  in  these  cases  is  no  doubt  the  muscular 
tissue  of  the  uterus  ;  and  the  suff*ering  from  this  cause  sometimes 
outlasts  that  time  of  life  during  which  menstruation  takes  place,, 
though  the  cessation  of  the  periodical  congestion  of  tlie  womb, 
which  occurs  so  long  as  the  sexual  system  retains  its  activity,  is 
followed  by  a  great  diminution  of  the  patient's  ills.  In  the  worst 
cases  of  this  disorder,  the  womb,  though  presenting  no  appreciable 
alteration,  is  so  intensely  tender,  that  the  slightest  movement 
causes  intolerable  pain  ;  and  many  instances  of  an  aftection  which 
the  late  Dr.  Gooch^  described  with  all  that  grapliic  skill  of  which 
he  was  so  great  a  master,  and  for  which  he  proposed  the  name  of 
the  Irritable  Uterus,  may  be  referred  to  this  category.  I  shall 
presently  have  a  few  remarks  to  make  on  the  treatment  of  this 
ailment;  just  now,  I  will  add  only  that  relief  for  it  is  to  besought 
by  measures  directed  to  the  constitutional  cause,  and  not  by  any 
form  of  local  medication. 

Such,  then,  are  the  two  principal  forms  of  dysmenorrhoea :  the 
one  the  neuralgic,  the  other  the  congestive ;  while  often  we  meet 

1  The  observations  of  Dr.  Todd  on  the  subject  in  section  ix,  of  Practical  Remarks 
on  Gout,  Rheiimatiam,  Fever,  ^-c,  8vo.,  London.  1843  ;  and  those  of  Dr.  Kigby,  in 
his  works  on  Dysmenorrhoea,  published  in  1844,  have  more  especially  called  atten- 
tion to  this  subject. 

2  On  the  More  Important  Diseases  of  IT'bmew,  8vo.,2d  cd.,  London,  1831,  p.  332. 


MECHANICAL    D  Y  S  M  E  NO  R  R  H  CE  A.  .73 

with  cases  presenting  tlie  mingled  cliaracteri sties  of  both  varieties. 
It  is  probable  that  in  all  of  these  cases  a  temporary  constriction  of 
the  internal  orifice  of  the  uterns  plays  a  more  important  part  than 
has  commonly  been  supposed  in  the  production  of  the  symptoms ; 
that  not  merely  is  there  a  non-effusion  of  the  menstrual  fluid,  but 
that,  even  after  it  has  been  poured  out,  a  condition  either  of  tur- 
gescence  or  of  spasm  at  the  internal  os  uteri  prevents  its  escape, 
and  keeps  up  or  aggravates  the  suffering  of  the  patient.'  Bat 
there  are  other  instances  in  which  the  influence  of  mechanical 
obstruction  is  both  more  obvious  i\nd  more  abiding.  Such  are 
those  in  which  the  painful  menstruation  is  associated  with  some 
organic  disease  of  the  uterus,  as  fibrous  tumor,  or  with  some  mal- 
position, as  anteflexion,  or  retroflection,  or  in  which  the  canal  of 
the  cervix,  or  its  orifice,  is  permanently  contracted.  The  existence 
of  any  of  these  conditions  can  of  course  be  ascertained  onl}^  by  a 
careful  vaginal  examination,  and  this  should  not  be  omitted 
wherever  the  dysmenorrhoea  continues  for  several  months  in  spite 
of  treatment  calculated  to  remove  it. 

Of  late  years  special  attention  has  been  directed  to  that  form  of 
so-called  mecJianical  dysmenorrhea,  in  which  the  patient's  sufferings 
are  due  to  the  contracted  cervix  obstructing  the  escape  of  the 
menstrual  fluid.  This  mechanical  form  of  dysmenorrhcea  is  char- 
acterized not  only  by  pain,  but  also  by  the  slow  escape  and  scanty 
amount  of  the  blood  discharged,  which  also,  for  tlie  most  part, 
escapes  in  small,  imperfectly  formed  coagula.  The  late  Dr.  IMack- 
intosh,  of  Edinburgh,^  was,  I  believe,  the  first  person  who,  in  the 
year  1823,  directed  attention  to  this  source  of  difficult  menstrua- 
tion, and  in  1826  he  advised  the  mechanical  dilatation  of  the  os 
uteri  by  bougies,  for  its  relief.  The  impediment  may  exist  either 
at  the  external  os  uteri,  or  at  some  limited  part  of  the  cervix, 
especially  at  the  internal  os,  where  the  body  and  neck  of  the 
womb  communicate,  or  it  may  involve  the  whole  of  its  canal.  It 
appears,  in  some  instances,  to  be  attributable  to  inflammation,  and 
probable  ulceration  of  the  cervical  canal,  as  in  the  case  of  a  woman 
once  under  my  care,  the  canal  of  whose  cervix  was  at  one  point  so 
nearly  obliterated  as  not  to  allow  the  passage  of  the  finest  catgut 
bougie,  and  who  referred  her  suflerings  to  the  effects  of  a  labor 
twelve  years  before.  In  other  instances,  the  dysmenorrhoea  is 
habitual,  and  the  narrow  cervix  is  a  congenital  condition,  or  one 
due  at  least  to  some  defect  of  uterine  development,  and  this  latter 
I  believe  to  be  the  more  frequent  form  of  the  atiection. 

An  impression  has  of  late  years  been  gaining  ground  that  this 
form  of  dysmenorrhoea  is  very  connnon,  and  mechanical  means 

1  Tlio  share  of  obstruction  to  the  outflow  of  the  menses,  from  the  temporary  eon- 
traction  of  the  cervical  orifice,  in  giving  rise  to  the  pain  of  dysmonorrhiea,  has  been 
dwelt  on  by  Dr.  Graily  Hewitt  in  his  recent  work  on  the  Diseases  of  \\'«»ie7i,8yo., 
London,  1803  (sec  pp.  119-125).  The  able  arguments  by  which  Dr.  Hewitt  sup- 
ports his  views  receive  further  corroboration  by  tiie  remarks  of  Mr.  Guyon,  to  which 
refor(;nce  has  already  been  made,  op.  cit.,  pp.  2U4-208. 

2  In  his  Practice  of  Physic,  4th  od.,  Svo.,  London,  1836,  vol.  ii,  pp.  401-436. 


74,  TREATMENT    OF    DYSMENORRHCEA. 

of  treating  it  have  accordingly  come  very  much  into  vogue;  to 
the  neglect,  it  is  to  be  feared,  in  many  instances,  of  those  internal 
remedies,  by  which  painful  menstruation  is  in  general  much  more 
^ppropri  itely  treated.  One  circumstance,  which  I  believe  to  have 
much  contributed  to  the  support  of  this  opinion,  is  the  fact,  that 
on  introducing  the  uterine  sound  an  obstacle  is  very  often  en- 
countered at  the  internal  os  uteri  to  the  passage  of  the  instrument 
into  the  cavity  of  the  Avomb.  That  this  obstacle,  however,  is  in 
reality  perfectly  natural,  can  be  readily  ascertained  on  the  dead 
subject,  since  even  after  the  removal  of  the  uterus  from  the  body, 
a  bougie  which  passes  with  ease  along  the  cervical  canal  will 
there  encounter  a  resistance  such  as  can  often  be  overcome  only 
b}'  considerable  effort,  or,  perhaps,  not  at  all,  though  a  smaller 
bougie  will  pass  at  once  with  perfect  facility,  and  the  uterus, 
when  laid  open,  will  be  found  to  be  perfectly  healthy.  The  con- 
striction in  this  situation  which  is  found  to  be  so  considerable 
even  after  death,  was  doubtless  in  these  and  many  other  instances 
far  greater  during  life,  and  yet,  in  spite  of  it,  the  history  of  such 
persons  often  gives  no  account  of  ditiicult  or  painful  menstruation.^ 
IS'or,  indeed,  need  this  surprise  us,  for  the  discharge  takes  place 
during  menstruation,  not  in  a  continuous  stream  as  the  urine  flows 
from  the  bladder,  but  oozes  from  the  interior  of  the  womb,  the 
blood  escaping  drop  by  drop  from  the  os  uteri.  If  the  aperture  be 
so  small  as  scarcely  to  allow  this  to  take  place,  menstruation  no 
doubt  may  be  rendered  very  painful ;  and  just  as  when  stricture 
of  the  urethra  exists,  the  bladder,  and  ureters,  and  kidneys,  be- 
come irritated,  and  disturbed  in  the  performance  of  their  functions, 
so  it  is  quite  conceivable  that  a  similar  state  of  the  cervix  uteri 
may  exert  the  same  influence  on  the  fanction  of  that  organ,  and 
render  the  menstrual  flux  scanty  in  quantity  and  morbid  in  char- 
acter, as  the  consequence  of  the  difficulty  in  its  discharge.  The 
natural  constriction  of  the  internal  uterine  orifice  is  probably  often, 
heightened  by  functional  disorder,  and  thus  becomes  the  occasion 
of  a  great  increase  of  the  patient's  sufl'erings.  It  by  no  means 
follows,  however,  that  all  cases  in  which  symptoms  of  obstruction 
are  present  require  mechanical  treatment,  any  more  than  that 
every  case  of  croup  or  laryngitis  is  at  once,  and  irrespective  of 
other  measures,  to  be  dealt  with  by  the  performance  of  tracheotomy. 
And  this  brings  me  to  notice  the  treatment  of  dysnienorrhoea, 
which  must  vary  just  as  its  forms  are  various.  In  the  dysmenor- 
rhoea  of  young  girls  in  whom  menstruation  is  not  yet  completely 
established,  our  efforts  must  chiefly  be  directed  to  bringing  about 
the  regular  performance  of  the  function  as  speedily  as  possible, 
and  there  is  reason  to  hope,  that  in  proportion  as  this  is  eftected, 
the  pain  will  by  degrees  diminish.  If,  however,  the  suftering  be 
so  severe  as  to  require  the  employment  of  remedies  specially  di- 
rected to  its  mitigation,  they  will  in  the  majority  of  instances  be 

1  The  fact  of  the  natural  constriction  of  the  uterine  canal  at  the  situation  of  the 
internal  os,  was  very  clearly  asserted  br  Dr.  Henry  Bennet  in  his  work  on  Injiam- 
mation  of  the  Uiej'us.     See  p.  3  of  the  4th  edition. 


TREATMENT    OF    DYSMENORRIICEA.  75 

such  as  are  applicable  for  the  relief  of  nervous  dysmenorrhoea. 
One  of  the  most  serviceable  of  these  are  the  hot  hip-bath,  which 
may  be  had  recourse  to  on  the  first  threatening  of  pain,  and  even 
twenty-four  or  thirty-six  bours  before  the  date  at  which  the  com- 
mencement of  the  menstrual  discharge  is  expected.  To  obtain 
the  full  benefit  from  it  the  patient  should  remain  in  it  for  half  or 
three-quarters  of  an  hour;  the  temperature  of  the  water  being 
maintained  during  the  whole  time  at  96°  or  9«°;  while  the  bath 
may  often  be  advantageously  rendered  more  stimulating  by  the 
addition  of  mustard  to  the  water.  If  pain  again  returns  with 
severity,  the  bath  may  be  repeated  twice  or  three  times  in  the 
twenty-four  hours,  while  after  its  employment  the  patient  should 
always  retire  to  bed,  and  remain  there  until,  with  the  establish- 
ment of  the  menstrual  flux,  the  pain  has^in  great  measure  sub- 
sided. It  will,  however,  still  be  wise  for  the  patient  to  remain 
during  tlie  whole  period  in  her  apartment,  and  to  avoid  all  exer- 
tion, as  well  as  all  changes  of  temperature. 

If  the  pain  be  very  severe,  some  sedative  or  narcotic  will  prob- 
ably be  indispensably  necessary,  and  this  will  be  likely  to  produce 
the  best  effect  if  taken  immediately  on  the  patient  coming  out  of 
her  bath.  Opium,  in  some  of  its  various  preparations,  is  of  course 
the  most  powerful  remedy ;  but  there  are  many  reasons  why  it  is 
undesirable  to  have  recourse  to  it,  unless  the  milder  sedatives 
have  been  tried  and  found  ineflicacious.  In  many  instances 
opium  deranges  the  digestive  functions  seriously,  and  inflicts  on 
the  patient  a  very  distressing  headache  for  hours  after  its  first 
soothing  influence  has  passed  off";  but  a  still  more  serious  objec- 
tion to  its  use  is  furnished  by  the  fact  that  young  women  not  sel- 
dom become  habituated  to  the  drug  from  having  had  recourse  to 
it  as  a  sort  of  domestic  remedy  for  deadening  the  pain  of  menstru- 
ation. In  many  instances  of  the  purely  neuralgic  dysmenorrhoea, 
"ether  alone  suifices  to  remove  the  pain,  or  at  least  greatly  to  mit- 
igate it;  and  when  this  is  so,  its  transitory  influence  and  the  cir- 
cumstances that  it  in  no  way  interferes  with  the  digestive  func- 
tions, render  it  far  preferable  to  any  of  the  more  direct  narcotics. 
A  draught  containing  half  a  drachm  of  the  compound  spirits  of 
ether,  and  fifteen  minims  of  chloric  ether,  will  generally  answer 
the  purpose  very  well,  while  in  cases  where  the  patient,  as  some- 
times happens,  has  an  insuperable  objection  to  the  taste  of  ether, 
the  eau  de  luce,  or  tinctura  ammoniiB  composita  of  the  Pharmaco- 
poeia, forms  a  very  good  substitute  for  it.^  A  single  dose  of  any 
of  these  remedies  will  often  sutfice,  but  if  not  they  may  be  re- 
peated frequently,  and  at  short  intervals.  Some  years  ago,  the 
Sumbul,  an  Inuian  remedy,  was  introduced  into  practice  as  appli- 

1  (No.  9.) 

R.    Tinct.  Ammonia' conipositiP,      ....  '^vj 

Tiiict.  Aiiraiitii, .^j 

Syrupi  simplicis, ,t  j 

Inf.  Auruntii  co., .^iv 

Mist.  Caniphorje, 5vj — M.  ft.  hsiustus. 


76  TREATMENT  OF  DYSMENORRHCEA, 

cable  to  the  relief  of  neuralgic  pains,  as  well  as  of  other  ailments. 
It  certainly  seems  to  possess  a  measure  of  that  compound  stimu- 
lant and  anodyne  property  which  characterizes  ether,  though  in  a 
far  inferior  degree.  You  will,  however,  always  find  it  useful  in 
the  management  of  the  diseases  of  women  to  have  numerous 
exjiedients  at  hand  for  the  relief  of  minor  ailments,  in  addition 
to  being  well  acquainted  with  the  great  remedies  for  more  seri- 
ous ills. 

Should  none  of  the  above-named  simpler  means  suffice,  hen- 
bane is  that  one  of  the  more  decided  narcotics  of  which  you  may 
make  a  trial  with  the  least  risk  of  its  disagreeing  with  the  patient. 
Forty  minims  of  the  tincture,  or  five  grains  of  the  extract,  are  an 
average  dose,  and  the  quieting  action  of  the  remedy  seems  to  be 
much  increased,  especially  in  the  case  of  uterine  pain,  by  combin- 
ing it  with  camphor,  five  grains  of  which  may  be  given  with  each 
dose  of  the  henbane.  Another  remedy  extremely  serviceable  in 
controlling  neuralgic  pain,  and  free  from  many  of  the  inconveni- 
ences of  opium,  is  the  Indian  hemp,  or  Cannabis  Indica.  There 
are  two  drawbacks,  however,  from  its  use.  The  one  is,  that  owing 
to  the  absence  of  any  officinal  preparation  of  the  drug,  the  medi- 
cine, as  ordered  from  dift'erent  druijsrists,  varies  much  in  strenirth; 
the  other  is  that  the  susceptibility  of  dilierent  persons  to  its  influ- 
ence varies  much  more  than  in  the  case  of  opium.  For  these 
reasons,  it  is  expedient  that  it  should  always  be  procured  at  the 
same  place,  and  also  that  it  should  always  be  ordered  in  a  mini- 
mum dose  at  first,  until  you  have  ascertained  its  effect  on  your 
patient.  The  inhalation  of  chloroform  or  ether,  though  its  effects 
are  Ijut  transitory,  yet  sometimes  exerts  a  permanent  influence  in 
mitigating  uterine  pain.  The  remedy,  however,  is  too  hazardous 
to  be  intrusted  to  the  patient  or  her  friends,  but  the  local  applica- 
tion of  chloroform  to  the  hypogastric  or  pubic  region,  is  not  only 
free  from  risk,  but  is  also  often  serviceable.  If  none  of  these 
means  give  relief,  opium  becomes  our  last  resource,  and  Dover's 
powder,  morphia,  the  sedative  solution  of  opium,  and  the  black 
drop,  are  all  of  them,  in  these  cases,  to  be  preferred  to  the  simple 
tincture,  because  they  generally  occasion  less  sickness  or  headache, 
and  are  less  apt  to  produce  constipation  of  the  bowels.  Some- 
times medicines  given  by  the  mouth  seem  unavailing,  or  the  se- 
verity of  the  pain  induces  us  to  seek  for  a  remedy  that  shall  be 
more  rapid  in  its  action,  and  in  these  circumstances  an  opiate 
suppository,  or  an  opiate  enema,  the  bulk  of  which  must  of  course 
be  very  small,  will  often  afford  speedy  relief 

I  do  not  think  it  will  be  out  of  place  if  I  here  very  strongly  ad- 
vise you  to  look  on  every  case  of  dysmenorrhoea  in  young  women 
as  of  importance,  and  not  content  yourselves  with  giving  a  few 
general  directions,  or  with  writing  a  prescription  for  your  patient, 
if  the  pain  from  which  she  suffers  should  chance  to  be  very  urgent. 
There  is  always  much  greater  risk  of  the  attacks  becoming  habit- 
ual, and  thus  rendering  your  patient's  future  life  miserable,  than 
there  is  reason  for  expecting  the  popular  belief  to  be  realized,  and 


OF    THE    CONGESTIVE    FORM.  77 

tliat  the  ailment  of  the  girl  will  spontaneously  cease  when  she  at- 
tains to  full  womanhood.  Every  precaution  which  I  have  sug- 
gested is  of  the  greatest  moment;  the  confinement  of  the  patient 
to  her  room,  the  absolute  rest,  the  repose  in  bed  during  the  early 
part  of  tlie  menstrual  period,  ar6  indispensable  with  each  return 
of  menstruation,  so  long  as  the  tendency  to  dysmenorrhoea  con- 
tinues, and  I  believe  are  much  more  important,  as  far  as  eventual 
permanent  recovery  is  concerned,  than  is  the  employment  of 
remedies  to  relieve  pain  on  any  single  occasion.  Your  care, 
moreover,  must  not  cease  with  the  cessation  of  the  attack,  but 
your  attention  must  be  most  watchful  during  the  menstrual  in- 
tervals, .to  correct  anything  wrong  in  the  general  health,  and  to 
invigorate  the  patient's  system,  which  in  these  cases  is  almost  al- 
ways feeble.  One  other  caution  you  must  allow  me  to  add :  there 
is  a  popular  impression  that  when  the  highest  functions  of  the 
sexual  system  are  brought  into  play,  many  ailments,  previously 
troublesome,  are  likely  to  cease,  and  it  is  beyond  a  doubt  that,  in 
some  instances,  marriage,  and  pregnancy,  and  childbcaring  are 
followed  by  these  desirable  results.  I  fear,  however,  that  the 
cliances  are  the  other  way;  that  the  girl  who  suffers  from  dys- 
menorrhoea will  be  likely  to  suffer  more  from  it  after  marriage 
than  she  did  before;  that  the  extreme  sensitiveness  of  her  uterine 
organs  will  render  marriage,  in  all  sexual  respects,  a  very  painful 
condition  ;  that  conception  will  be  less  likely  to  occur  than  in  an- 
other woman,  and  that  if  it  should,  pregnancy  and  labor  will  be 
attended  by  far  more  than  the  usual  amount  of  distress.  •  If  this 
be  so,  however,  you  must  see  how  cogent  the  reasons  are  for  treat- 
ing dysmenorrhoea  more  gravely  than  may  at  first  sight  appear 
necessary.  Good  taste  and  good  feeling  will  not  fail  to  guide 
you  in  selecting  the  best  way  of  conveying  your  opinions  to  your 
patient  and  her  friends,  and  you  will  most  likely  find  a  ready  ac- 
quiescence in  your  directions  so  soon  as  the  grounds  on  which 
they  rest  are  clearly  understood. 

In  the  congestive  form  of  dysmenorrhoea,  anodj-nes  no  longer 
furnish  the  ready  resource  for  the  relief  of  present  sufiefing  which 
they  supply  in  tlie  neuralgic  variety  of  the  afi'ection.  The  uterus 
and  the  pelvic  viscera  generally  are  overloaded  with  blood,  and  it 
is  only  by  its  abstraction  that  we  can  relieve  the  patient.  Cup[)ing 
to  the  sacrum,  or  the  application  of  leeches  to  the  hypogastrium, 
the  anus,  or  the  uterus  itself,  are  the  means  by  which  this  end  is  to 
be  accomplished.  It  is  not  in  general,  however,  that  the  abstraction 
of  so  large  a  quantity  of  blood  as  seems  implied  in  the  ai)plicatiou 
of  the  cu[)ping-glasses  is  necessary  or  desirable.  The  great  benefit 
of  leeching  the  hy[togastric  or  iliac  region  seems  to  be  confined  to 
those  cases  in  which  the  pain,  referred  especially  to  the  sides  of  the 
pelvis,  indicates  the  ovaries  to  be  its  seat ;  but  in  other  oases  it  is 
decidedly  inferior  in  efiicacy  to  the  application  of  leeches  to  the 
anus.  These  modes  of  abstracting  blood  can  be  resorted  to  at  any 
time,  even  just  before  menstruation  or  during  the  i)resence  of  the 
discharge;  leeches  cannot,  however,  be  applied  to  the  uterus  itself 


78  TREATMENT    OF 

within  tliree  or  four  days  of  an  expected  menstruation  without 
considerable  risk  of  disturbing  the  regularity  of  its  return. 

"When  depletion  has  been  resorted  to,  the  tepid  hip-bath  will 
generally  afibrd  some  relief,  while  afterwards  the  patient  should 
remain  in  bed,  and  take  some  diaphoretic  saline,  such  as  the  liquor 
ammouife  acetatis,  combined  with  small  doses  of  henbane  or  of 
opium,  the  efficacy  of  which  remedy  will  in  these  cases  be  much 
increased  by  combining  it  with  nauseating  doses  of  tartar  emetic. 
In  some  cases  of  this  description  the  direct  narcotics  in  any  form 
or  combination  are  ill  borne,  exciting  much  constitutional  dis- 
turbance, and  relieving  the  pain  but  little  or  not  at  all.  Ipe- 
cacuanha in  grain  or  half-grain  doses,  every  hour  till  a ,  decided 
nauseating  efiect  is  produced,  is  in  these  circumstances  sometimes 
of  very  great  service,  aftbrding  much  relief  to  the  pain,  and  also 
lessening  the  amount  of  discharge,  which  otherwise  not  infre- 
quently becomes  over-profuse  about  the  second  or  third  day  of 
menstruation. 

The  treatment  of  the  patients  at  the  menstrual  period  comprises, 
however,  only  a  small  part  of  what  is  needed  to  bring  about  their 
cure.  Though  relieved  for  a  season  by  the  flow  of  blood,  as  is 
generally  the  case,  the  S3'mptoms  by  degrees  return  before  the 
next  period  comes  on.  It  is  during  this  interval  that  so  much  is 
gained  by  local  depletion  of  the  uterus;  a  proceeding  w4iicli, 
although  abundantly  simple,  I  ma}',  perhaps,  as  well  stop  for  a 
moment  to  describe  to  3'ou. 

Leeches,  when  applied  to  the  womb,  generally  produce  a  much 
greater  flow  of  blood  than  follows  their  application  to  any  external 
part ;  and  four,  or  at  the  most  six,  are  therefore  as  many  as  it  is 
desirable  to  put  on  at  one  time.  Metallic  tubes,  perforated  with 
holes  at  one  end,  and  capable  of  being  closed  by  a  plug  at  the 
other,  and  some  other  similar  contrivances,  are  sold  in  instrument 
makers'  shops,  and  are  very  useful  for  servants  or  nurses,  when- 
ever they  are  intrusted  with  the  operation  of  leeching  the  womb. 
I  prefer,  however,  to  employ  a  speculum,  and  generally  use  one  of 
Fergusson's  reflecting  glass  speculums,  by  which  you  can  both 
ascertain  more  exactly  the  part  to  which  to  apply  the  leeches,  and 
also,  if  the  os  uteri  be  at  all  open,  have  the  op[)ortunity  of  inserting 
into  it  a  little  bit  of  cotton-wool,  in  order  to  prevent  the  leeches 
biting  within  the  canal  of  the  cervix ;  since  that  accident  always 
gives  most  acute  pain,  though  otherwise  the  operation  is  attended 
by  very  little  sutiering.  The  speculum  being  introduced  and 
adjusted  as  the  patient  lies  upon  her  left  side,  the  leeches  are  put 
into  it,  and  then  pushed  up  to  the  uterus  by  means  of  a  little 
cotton-wool  or  lint,  which  may  be  withdrawn  in  five  or  ten  minutes, 
the  leeches  having  generally  bitten  l)y  that  time.  'Now  and  then 
a  leech,  crawling  out  of  the  speculum,  will  make  its  way  do'wn 
between  the  instrument  and  the  vaginal  wall,  and  fixing  on  the 
external  parts,  will  cause  much  pain  ;  but  a  little  care  will  enable 
you  to  guard  against  any  such  mischance.  I  would  not  have  taken 
up  your  time  with  details  which  may  seem  so  trivial,  if  it  were  not 


CONGESTIVE    DYSMENORRHEA.  79 

that  ill  the  country  you  maybe  uuable  to  command  the  services  of 
a  cLass  of  women  who  in  London  get  a  very  good  living  by  leeching 
the  uterus  under  medical  direction.  After  the  leeches  have  come 
away,  a  w^arm  liip-bath  is  generally  a  comfort  to  the  patient;  and, 
unless  the  bleeding  has  been  very  profuse,  is  desirable  as  a  means 
of  promoting  it,  on  the  same  principle  as  we  often  put  on  a  poul- 
tice after  the  application  of  leeches  externally.  The  evening  is 
generally  the  best  season  for  applying  leeches  to  the  womb,  in 
order  that  the  rest  and  sleep  of  tiie  coming  night  may  relieve  the 
patient,  jaded  and  wearied  by  the  discomfort  of  the  operation. 

I  may  just  add,  that  it  has  been  advised,  as  a  more  expeditious 
and  less  irksome  mode  of  depleting  the  uterus,  to  scarity  its  lips 
through  a  speculum  by  means  of  a  sharp  lancet  affixed  to  a  long 
handle.  Such  scarifications  are  by  no  means  painful,  and  in  some 
instances  where  the  mucous  membrane  covering  the  lips  of  the 
uterus  is  the  seat  of  undue  vascularity,  and  presents  a  peculiar 
granular,  abraded  appearance,  I  have  seen  nmch  benefit  result 
from  it,  just  in  the  same  manner  as  scarification  of  the  palpebral 
conjunctiva  sometimes  does  much  good  in  strumous  and  other 
forms  of  ophthalmia.  We  cannot,  however,  abstract  by  this  means 
any  considerable  amount  of  blood;  and  whenever  there  is  much 
congestion  of  the  vessels  of  the  uterine  substance,  which  we  are 
anxious  to  relieve  by  depletion,  leeches  to  the  part  are  always  to 
be  preferred. 

Depletion,  attention  to  the  bowels,  a  nutritious  but  unstimulat- 
ing  diet,  and  all  those  little  precautions  which  come  under  the 
somewhat  vague  denomination  of  attention  to  the  general  health, 
must  in  all  of  these  cases  engage  our  care  during  the  intervals 
between  each  menstrual  period.  When  to  this  1  add,  that  the 
backache,  if  not  relieved  by  a  plaster,  generally  yields  to  a  croton 
oil  liniment,  sufficiently  weak  not  to  produce  a  troublesome  pustu- 
lar eruption,  and  that  small  blisters  in  one  or  other  iliac  region 
usually  mitigate  the  pain  referred  to  the  situation  of  the  ovaries, 
I  think  I  have  given  you  all  the  special  directions  which  are  ap- 
plicable to  cases  of  this  description. 

I  have,  howerer,  referred  to  some  instances  in  which  the  painful 
menstruation  is  associated  with  various  evidences  of  a  rheumatic 
or  gouty  diathesis,  and  such  cases  are  both  peculiarly  painful  and 
peculiarly  intractable.  Colchicum  is  often  of  much  utility,  and 
during  the  paroxysm  twenty  or  thirty  minims  of  the  tincture  in 
combination  with  small  doses  of  laudanum  and  of  antimonial 
wine,  will  often  give  more  relief  than  any  other  remedies,  and 
prove  especially  useful  when  large  doses  of  narcotics  will  be  of 
no  service.  The  treatment  during  the  menstrual  intervals  is  of 
particular  importance  to  this  class  of  patients,  and  yet  so  various 
are  the  symptoms  in  difierent  cases,  that  it  is  impossible  to  lay 
down  any  definite  plan  as  applicable  to  all.  So  long  as  the  bowels 
are  very  constipated,  as  the  tongue  is  foul,  and  the  urine  loaded 
with  lithates,  colchicum  may  be  given  two  or  three  times  a  day, 
combined  with  the  sulphate  and  carbonate  of  magnesia,  and    a 


80  TREAT MENTOP 

small  dose  of  blue  pill  or  gray  powder  with  the  extract  of  poppy  or 
of  henbane  at  night.  When  the  constipated  state  of  the  bowels  has 
been  overcome,  the  acetous  extract  of  colchicum  may  still  be 
continued  at  night,  while  during  the  day  some  mild  tonic  is  given, 
such  as  the  nitromuriatic  acid  with  extract  of  taraxacum,  or  the 
liquor  cinchonse  and  taraxacum  ;  for  with  the  disposition  to  local 
plethora  and  congestion  there  is  almost  always  associated  a  gen- 
eral want  of  power  in  the  system.  While  the  tonic  plan  is  gen- 
erally pursued,  any  increase  of  pain,  or  irritability  of  the  bladder, 
or  an  increased  deposit  of  lithates  in  the  urine,  will  call  for  a 
return  to  the  use  of  the  colchicum,  and  its  employment  with 
greater  frequency.  The  persistence  of  the  symptoms  and  the  pres- 
ence of  a  profuse  leucorrhoeal  discharge,  as  well  as  of  an  habitual 
excess  of  lithates,  indicates  the  employment  of  the  iodide  of  po- 
tassium, which  is  often  of  great  service  when  the  colchicum  has 
already  disappointed  our  expectations.  The  dysuria  in  these  cases 
is  frequently  much  relieved  by  the  patient  drinking  Vichy  water 
instead  of  spring  water ;  while  the  form  of  tonic  that  in  general 
suits  best  is  the  citrate  of  iron  in  doses  not  exceeding  five  grains 
twice  a  day,  for  which  the  Vichy  water,  sweetened  with  a  little 
syrup  of  orange-peel,  is  a  very  agreeable  vehicle.  Lastly,  when 
this  condition  has  existed  for  years,  it  becomes,  I  fear,  almost  in- 
curable. The  waters  of  Carlsbad  and  of  Wiesbaden  do,  indeed, 
efiect  something  towards  the  alleviation  of  the  patient's  sutier- 
ings,  sometimes,  perhaps,  even  bring  about  a  cure,  but  at  the  best 
slowly,  uncertainly,  and  leave  behind  a  great  disposition  to  relapse. 
Hence  the  wealthy  lose  heart  at  what  seems  to  be  a  never-ending 
treatment,  requiring  to  be  renewed  year  after  year,  and  imposing, 
as  the  price  of  even  moderate  success,  strict  self-denial,  and  precau- 
tions which  almost  exclude  from  society  those  who  observe  them. 
The  poor,  unable  to  afford  the  luxury  of  illness,  are  at  least  as 
unfortunate,  and  endure  a  life  of  wearing  pain,  all  the  more  in- 
tolerable, perhaps,  from  its  depending  on  no  dangerous  disease, 
and  tending  but  little  to  shorten  an  existence  which  it  yet  renders 
extremelj'  miserable. 

With  reference  to  the  last  form  of  dysmenorrhoea — namely,  that 
dependent  on  the  permanent  contraction  of  the  os  and  cervix  uteri, 
and  the  consequent  mechanical  impediment  to  the  escape  of  the 
menstrual  fluid — I  have  already  expressed  my  conviction  of  its  rare 
occurrence,  and  am  far  from  being  alone  in  this  opinion.^  In 
some  instances  in  which  this  was  supposed  to  be  the  cause  of 
painful  menstruation,  the  result  of  careful  examination  has  been  to 
show  that  the  cervix  was  small,  and  its  canal  narrow,  just  because 
the  sexual  organs  generally  were  undeveloped.  Such  cases  I  need 
not  say,  are  not  cases  of  mechanical  dysmenorrhoea,  nor  to  be 
relieved  by  any  attempt  at  dilating  the  cervix.  Nor,  indeed,  as  I 
have  alread}'^  stated,  are  the  symptoms  of  menstrual  obstruction 
which  accompany  many  cases  of  neuralgic  or  congestive  dysmenor- 

'  See  with  reference  to  this  very  point,  the  remarks  of  M.  Aran,  op.  cit.,  p.  324 


MECHANICAL    DYSMENORRHCEA.  81 

rha3a,  to  be  looked  on  as  conclusive  evidence  of  abiding  contrac- 
tion of  the  neck  of  tlie  womb,  I  agree  with  M.  Aran  in  regarding 
as  the  best  proof  of  that  condition,  the  painful  discharge  of  small 
coagnla,  recurring  at  several  successive  monthly  periods,  instead 
of  an  outflow  of  healthy  menstrna^fluid. 

To  judge,  indeed,  by  the  multiplicity  of  contrivances  which  of 
late  years  have  been  employed  for  the  purpose  of  dilating  the  cervix 
uteri,  you  would  be  led  to  a  difi'erent  conclusion  from  that  whieh  I 
believe  to  be  the  right  one ;  and  would  suppose  that  the  existence 
of  a  narrow  cervix  uteri  was  of  great  frequency.  In  addition  to 
ordinary  bougies,  such  as  were  employed  by  Dr.  Mackintosh,  and  to 
bougies  of  flexible  metal,  which  have  been  found  in  some  respects 
more  convenient,  metallic  stems  with  bulbous  ends  have  been  in- 
troduced, and  left  in  the  cervical  canal  for  an  hour  or  two  at  a  time ; 
and  these  stems  have  been  recentlj'  modified  by  constructing  tliem 
of  two  dift'erent  metals  with  the  view  of  obtaining  some  kind  of 
galvanic  action  in  the  interior  of  the  uterus.  These  ingenious  con- 
trivances are  the  inventions  of  Professor  Simpson  of  Edinburgh.  I 
apprehend,  however,  that,  as  in  the  case  of  the  galvanic  rings  which 
some  time  ago  were  sold  about  the  streets  for  the  cure  of  neuralgic 
and  rheumatic  aftections,  so  in  the  case  of  these  stems,  the  amount  of 
galvanic  action  set  up  must  be  too  slight  to  exert  any  real  influence ; 
while,  independent  of  the  difficulty  which  there  always  is,  especi- 
ally if  the  vagina  be  narrow,  in  their  introduction,  the  effect  of 
allowing  metallic  bougies  to  remain  for  any  considerable  time  in 
contact  with  the  interior  of  the  uterus  has  almost  always  appeared 
to  me  to  be  that  of  producing  very  considerable  suffering. 

Besides  the  gradual  dilatation  of  the  os  and  cervix  uteri  by 
bougies,  instruments  not  unlike  the  speculum  matricis  of  the  an- 
cients have  been  devised  for  forcibl3^  widening  it,  literally  screw- 
ing it  open,  and  others  for  incising  it  b}'  means  of  a  bistoire  cache. 
I  am  perfectly  at  a  loss  as  to  the  principle  upon  which  these  in- 
struments are  recommended.  If  the  cervix  uteri  be  wide  enough 
to  admit  them,  I  do  not  see  how  its  narrowness  can  offer  a  mechani- 
cal impediment  to  the  escape  of  the  menses.  I  can,  however, 
readily  understand  that  the  uterus  may  suffer  severely  from  the 
violence  offered  to  it,  and  indeed  have  known  pelvic  abscesses 
succeed  to  some  of  these  manipulations. 

These  proceedings  are,  I  believe,  nmch  less  frequently  resorted 
to  now^,  since  the  mischief  to  which  they  are  likely  to  lead  has 
become  more  evident  than  it  was  a  few  years  ago.  I  cannot, 
however,  refrain,  now  that  the  opportunity  presents  itself,  from 
warning  you  against  plausible  errors  such  as  led  to  this  practice  ; 
errors  into  which  you  are  all  the  more  likely  to  fall,  from  their 
being  of  a  kind  to  receive  speedy  ciirrency  among  our  patients. 
Non-professional  persons  cannot  understand  the  reasotis  which 
induce  us  to  adopt  one  course  of  medical  treatment  instead  of 
another;  but  they  can  quite  understand  th6  popularized  pathology 
which  tells  them  that  they  menstruate  with  pain  i)ecause  the  pas- 
sage of  the  womb  is  too  narrow,  and  in  the  hope  of  a  cure  will 

6 


82  DISEASES    OF    THE    UTERUS. 

submit  with  readiness  to  almost  any  amount  of  mechanical  treat- 
ment ;  and  will  perhaps  draw  comparisons  between  the  doctor  who 
is  resorting  to  very  needless  interference  and  the  less  officious 
person  who  did  no  more  than  the  necessities  of  the  case  required — 
comparisons,  I  scarcely  need  st^,  very  unfavorable  to  the  latter. 

If  now,  after  taking  all  possible  care  to  avoid  mistakes,  you  still 
come  to  the  conclusion  that  the  painful  menstruation  is,  in  part,  if 
not  altogether,  due  to  the  narrow  cervical  canal,  I  think  you  will 
find  a  set  of  flexible  metallic  bougies  the  best  and  most  convenient 
means  for  dilating  the  passage.  Those  which  I  use  correspond  in 
size  with  the  sounds  employed  by  surgeons  for  examining  the 
bladder;  but  I  have  had  a  notch  made  at  two  and  a  half  inches 
from  the  extremity,  in  order  to  be  able  to  tell  how  far  the  instru- 
ment has  been  introduced.  Five  or  ten  minutes  are,  I  think,  as 
long  a  time  as  it  is  desirable  to  allow  the  bougies  to  remain  ;  but 
they  should  be  introduced  daily,  and  their  employment  should  not 
be  discontinued  until  the  canal  admits  one  corresponding  to  the 
ordinary  ISTo.  9  bougie.  If  after  frequent  attempts  the  bougie  can 
be  introduced  only  a  short  distance,  a  prepared  sponge  tent,  such 
as  Professor  Simpson  was  the  first  to  bring  into  use,  should  be 
introduced,  and  then  a  larger,  and  still  larger,  till  in  the  course  of 
a  couple  of  days  the  cervix  will  be  widely  dilated  throughout:  or 
else  we  shall  find  the  point  at  which  a  decided  impassable  contrac- 
tion exists.  In  the  only  case  in  which  I  discovered  this  state  of 
things,  the  patient's  sufferings  dated  from  a  severe  confinement, 
and  the  stricture  close  to  the  internal  os  uteri  w^ould  not  allow  the 
passage  of  the  smallest  catgut  bougie.  In  this  instance  I  employed 
Staftbrd's  instrument  for  dividing  impermeable  urethral  stricture  ; 
and  the  result  of  this  proceeding,  and  of  the  subsequent  introduc- 
tion at  first  of  sponge  tents,  and  afterwards  of  metallic  bougies,  to 
keep  the  passage  pervious,  was  in  the  highest  degree  satisfactory. 

In  no  other  case,  however,  has  the  employment  of  a  cutting 
instrument  for  widening  a  narrow  cervix  uteri  appeared  to  me 
either  necessary  or  proper. 


LECTURE    VI. 

DISEASES  OF  THE  IJTEKUS. 

Immediate  results  of  pregnancy  and  delivery  not  treated  of,  though  their  remote 
effects  are  numerous  and  important. 

Inflammation,  and  kindred  processes. 

Hypertrophy  of  the  Uterus  from  deficient  involution  after  delivery  or  abor- 
tion— from  uterine  irritation.  Illustrative  cases,  and  treatment.  Partial  hy- 
pertrophy affecting  the  cervix;  its  effects.  Treatment,  removal  of  enlarged 
cervix,  dangers  of  hemorrhage. 

Inflammation.  Acute  Inflammation  ;  its  rarity,  its  causes,  symptoms,  and 
results.    Treatment. 

A  COURSE  of  lectures  on  the  diseases  of  women,  in  which  it  is 
not  proposed  to  include  the  ailments  either  of  the  pregnant  or  ot 


INFLAMMATION    A    CAUSE     OF     UTERINE    DISEASE.        83 

the  puerperal  state,  must  needs  present  much  that  is  defective  in 
arrangement  and  incomplete  in  execution.  These  defects,  how- 
ever, appear  to  me  to  be  a  smaller  evil  than  would  be  the  occupy- 
ing of  much  of  your  time  with  the  reconsideration  of  subjects 
such  puerperal  fever,  or  phlegmasia  dolens,  which  have  ah'eady 
come  before  your  notice  in  the  lectures  on  midwifery,  and  which, 
besides,  have  engaged,  and  to  such  good  purpose,  the  attention  of 
many  writers  both  in  this  country  and  on  the  continent. 

Sacrificing,  therefore,  accuracy  of  nosological  arrangement  to 
practical  convenience,  I  shall  leave  unnoticed  alike  the  special  dis- 
eases of  pregnancy,  and  the  morbid  conditions  which  follow  im- 
mediately on  delivery.  We  shall  find,  however,  over  and  over 
again,  that  conception,  pregnancy,  and  delivery,  are  among  the 
most  frequent  exciting  causes  of  disorder  of  the  sexual  functions, 
and  of  diseases  of  the  sexual  organs,  and  also  that  many  ailments 
which  come  under  our  care,  days,  or  weeks,  or  even  months  after- 
wards, admit  of  being  traced  back  uninterruptedly  to  their  com- 
mencement in  a  miscarriage,  or  a  severe  confinement,  or  in  some 
interruption  to  the  changes  that  should  occur  in  the  puerperal 
state.  This  is  especially  the  case  with  all  the  diseases  which  are 
the  result  of  inflammation,  or  of  kindred  processes,  such  as  pelvic 
abscesses,  hypertrophy  of  the  uterus,  induration  of  its  cervix,  or 
ulceration  of  its  orifice,  with  all  the  varied  forms  of  menstrual 
disorder  and  of  leucorrhoeal  discharge  which  attend  upon  them. 

The  active  forms  of  inflammation  of  the  sexual  organs,  which 
threaten  life  soon  after  delivery,  are  not,  however,  those  whose 
sequelae  most  frequently  present  themselves  to  our  notice  in  hos- 
pital practice,  or  call  for  our  attention  in  private.  In  many  of 
these  the  local  mischief  is  but  a  part  of  the  disease,  one  of  the 
consequences  of  that  altered  condition  of  the  blood  in  which  the 
essence  of  puerperal  fever  consists,  and  contributes  only  in  a 
secondary  degree  to  imperil  or  destroy  the  patient's  life.  In  such 
cases,  if  the  patient  survive  the  constitutional  malady,  the  local 
mischief  is  slowly  but  surely  repaired  during  the  course  of  her 
tedious  convalescence,  and  the  sexual  organs,  restored  to  their  in- 
tegrity, resume  in  time  the  healthy  performance  of  their  functions. 
In  other  instances,  where  the  affection  has  been  from  the  com- 
mencement purely  local,  the  severity  of  the  attack  and  the  in- 
tensity of  the  suffering  usually  lead  to  corresponding  activity  and 
decision  in  the  treatment,  while  the  sense  of  past  danger  inspires 
in  the  patient  and  her  friends  the  observance  of  most  minute  pre- 
cautions until  her  health  is  completely  re-established.  Hence  it 
results  that  the  great  majority  of  cases  of  inflammation  and  enlarge- 
ment of  the  womb,  of  intiammation  of  the  uterine  appendages,  or 
of  suppuration  in  the  pelvic  cellular  tissue,  which  date  back  to 
pregnancy,  miscarriage,  or  delivery,  weeks  or  months  before,  are 
not  only  chronic  in  their  course,  but  were  attended  from  the  very 
outset  by  symptoms  of  comparatively  slight  severity,  and  mani- 
fested themselves  by  a  state  of  ailing  rather  than  of  serious  illness; 
or  succeeded  to  a  sort  of  imperfect  convalescence,  for  the  iucom- 


84  UTERINEDISEASE 

pleteness  of  whose  character  no  adequate  cause  appeared  for  some 
time  assignable. 

One  result  of  inflammation  succeeding  to  miscarriage  or  delivery 
is  to  checTc  that  process  of  invohition  by  which  the  womb  ought  to  be 
restored  in  a  few  weeks  to  the  size  and  condition  which  it  presented 
before  pregnancy  began.  If  jow  examine  the  body  of  a  woman 
who  died  of  uterine  inflammation  after  delivery,  one  of  the  first 
things  to  arrest  your  attention  will  be  the  large  size  of  the  womb, 
which,  after  the  lapse  of  four  or  five  days,  will  be  found  to  be  as 
large  as  the  healthy  womb  when  only  twenty-four  or  thirty-six 
hours  have  passed  since  the  completion  of  labor.  This  increased 
size  of  the  uterus,  too,  is  not  due  simply  to  its  natural  contractions 
being  arrested,  nor  to  the  unusual  afilux  of  blood  towards  it,  nor 
to  the  eflusion  of  the  products  of  inflammation  into  its  substance, 
though  possibly  all  of  those  causes  may  in  various  degrees  con- 
tribute to  it;  but  is  in  a  great  measure  owing  to  the  mei-e  suppres- 
sion of  those  changes  which  ought  to  occur  after  delivery,  and 
with  whose  nature  the  microscope  has  made  us  in  some  measure 
acquainted.  In  a  perfectly  healthy  condition,  a  large  amount  of 
the  blood  previously  supjilied  to  the  uterus  is  at  once  cut  ott"  by 
the  powerful  contractions  which  either  completely  close  the  vessels 
distributed  through  its  substance,  or  at  an}'  rate  greatly  diminish 
their  calibre.  Its  tissue  having  performed  the  function  for  which 
it  Avas  raised  during  pregnancy  to  so  high  a  degree  of  development, 
undergoes,  as  other  tissues  do  previous  to  removal,  a  process  of 
degradation  or  fatty  degeneration  ;  and  having  thus  become  more 
readily  susceptible  of  removal,  is  either  absorbed,  or  is  discliarged 
with  the  lochia  from  the  interior  of  the  womb.  For  some  three  or 
four  weeks,  little  else  goes  on  besides  this  process  of  degradation 
and  removal,  and  this  is  much  more  active  during  the  second 
week'  after  delivery,  than  either  before  or  after  that  period.  There 
next  begins  a  process  of  reconstruction  of  the  organ  ;  and  nuclei, 
and  caudate  cells,  and  elements  of  new  fibres  are  formed,  which 
await  only  the  stimulus  of  a  fresh  conception  to  attain  the  same 
perfection  of  structure  as  was  manifest  in  the  former  uterus. 
Observers  are  not  altogether  agreed  as  to  how  soon  this  repara- 
tive action  begins ;  whether  it  is  quite  secondary  to  the  removal 
of  the  elements  of  the  old  uterus,  or  whether,  as  seems  indeed 
most  likely,  removal  of  the  old  and  construction  of  the  new  go 
on  actively  at  the  same  time.  The  interior  of  the  uterus  under- 
goes changes  as  considerable  as  those  which  take  place  in  its 
substance ;  and  it  is  not  until  its  lining  membrane,  with  the  ex- 
ception of  that  of  the  cervix,  has  been  several  times  reproduced 
and  then  cast  off  in  a  state  of  fatty  degeneration,  that  it  resumes 
the  same  condition  as  before  impregnation.^ 

1  According  to  Heschl,  Wiener  Zeitschrift,  and  Schmidt,  Jahrbiicher^  vol.  Ixxvii, 
1853,  p.  341. 

2  The  best  microscopic  observations  on  this  subject  are  those  of  the  late  Franz 
Kilian  in  Henle's  Zeitschrift^  vol.  viii,  p.  53,  and  vol.  ix,  p.  1,  with  which  those 
of  Heschl,  loc.  cit.,  generally  correspond,  though  there  are  some  difl'erences  between 


FROM  INTERRUPTED  PUERPERAL  CHANGES.      8o 

The  occurrence  of  inflammation  appears  to  interrupt  these  pro- 
cesses, for  though  fatty  degeneration  of  the  tissues  takes  place, 
yet  the  removal  of  the  useless  material  is  hut  imperfectly  accom- 
plished, while  the  elements  of  the  new  uterus  are  themselves,  as 
soon  as  produced,  suhjected  to  the  same  alteration,  and  the  organ 
remains,  long  after  all  active  mischief  has  passed  away,  increased 
in  size,  and  at  the  same  time  composed  of  a  tissue  inapt  for  all 
the  physiological  processes  of  conception,  pregnancy,  and  child- 
bearing.  I  cannot  pretend  to  tell  you  the  intimate  nature  of  the 
changes  which  the  uterine  substance  in  these  cases  may  afterwards 
undergo,  for  the  microscope  here  leaves  us  for  the  present  at  fault, 
and  many  circumstances  will  always  render  the  investigation  of 
the  effects  of  inflammation,  and  of  its  kindred  processes  when 
seated  in  the  womb,  particularly  difficult.  It  must,  however,  be 
at  once  apparent,  that  after  inflammation  has  passed  aAvay,  its 
eflects  ma}'  remain  in  the  larger  size  and  altered  structure  of  the 
womb,  and  that  the  very  nature  of  these  changes  will  be  such  as 
to  render  the  repair  of  the  damaged  organ  both  unlikely  to  occur, 
and  slow  to  be  accomplished,  and  must  leave  it  in  a  condition  pe- 
culiarly liable  to  be  aggravated  during  the  fluctuations  of  circula- 
tion, and  alternations  of  activity  and  repose,  to  wliich  the  female 
sexual  system  is  liable.  It  must  also  be  obvious  that  for  these 
results  to  be  produced,  it  is  by  no  means  necessary  that  the  inflam- 
mation be  very  severe  in  character,  but  that  a  degree  of  inflamma- 
tory action  far  short  of  what  is  requisite  to  endanger  life  or  to 
occasion  much  suffering,  may  yet  interpose  a  great  obstacle  to  the 
complete  involution  of  the  womb. 

The  importance  of  this  condition  is  due  less  to  the  symptoms 
to  which  it  gives  rise,  so  long  as  it  remains  uncomplicated,  than  to 
the  circumstance,  that  complications  of  some  kind  or  other  are 
very  apt  to  occur;  that  the  heavy  uterus  is  very  likely  to  become 
prolapsed,  or  the  enlarged  uterus  to  become  the  seat  of  permanent 
congestion,  or  to  be  attacked  by  chronic  inflammation.  A  sense 
of  weight  in  the  pelvis,  more  or  less  bearing  down,  and  a  dispo- 
sition to  excessive  and  over-frequent  menstruation,  are  seldom 
absent  when  any  considerable  uterine  enlargement  exists,  and  in 
general  the  size  of  the  womb  and  the  severity  of  the  symptoms 
are  in  direct  proportion  to  each  other. 

One  of  the  best-marked  instances  of  this  deficient  involution  of 
the  uterus  which  I  have  met  Avith,  occurred  in  the  person  of  a 
woman  aged  thirty-one,  who  had  been  married  twelve  years,  and 
had  given  birth  to  five  children  at  the  i'nll  period,  and  had  also 
miscarried  three  times.  Her  last  abortion  occurred  at  the  third 
month,  six  weeks  before  her  admission  into  St.  Bartholomew's 
Hospital.  Since  this  abortion  she  had  suft'ered  from  shooting 
pains  at  the  lower  part  of  the  back  and  in  the  abdomen,  from 

their  statements  in  points  of  detail.  Dr.  Simpson  was,  I  believe,  the  first  to  call 
attention  to  the  praetical  bearings  of  the  subject.  See  his  Contributions  to  Obstetric 
Patholopy,  vol.  i,  p.  'Jfi. 


86  ENLARGEMENT    OF    THE    UTERUS 

bearing  down  pain  during  every  effort  at  defecation,  and  from  a 
constant  sanguineous  discharge,  by  which  she  had  been  much  ex- 
hausted. The  medical  man  under  whose  care  she  had  been,  told 
her  that  she  had  a  tumor  in  the  womb.  On  examination  the 
uterus  was  found  low  down,  completely  retroverted,  the  os  uteri 
being  directed  forwards,  and  onh'  a  short  distance  from  the  vulva. 
Almost  immediately  behind  the  os,  the  titerus  swelled  out  into  a 
globular  tumor  of  the  size  of  a  small  apple,  elastic  to  the  touch. 
The  canal  of  the  cervix  was  open  so  as  to  admit  the  finger  with- 
out difficulty.  On  introducing  the  uterine  sound,  it  passed,  with 
the  concavity  turned  backward,  for  a  distance  of  five  inches  and 
three-quarters,  and  on  turning  it  round,  the  tumor  previously  dis- 
tinguished complete!}'  disappeared.^ 

The  patient  was  kept  quiet  in  bed,  was  allowed  a  little  wine 
and  meat  diet,  and  the  hemorrhage  ceased,  and  the  canal  of  the 
cervix  contracted  under  the  use  of  the  ergot  of  rye,  though  no 
sensible  uterine  action  was  excited  by  the  remedy.  She  afterwards 
took  preparations  of  iron,  and  began  the  employment  of  the  cold 
douche  to  the  uterus,  by  which  she  was  already  much  benefited, 
though  the  -uterus  was  not  much  diminished  in  size,  when  the 
outbreak  of  small-pox  in  the  ward  compelled  me  to  discharge  her 
eighteen  days  alter  her  admission.  I  saw  her  three  months  after- 
wards; her  health  was  much  improved,  but  she  complained  of 
profuse  menstruation,  returning  every  fortnight,  and  her  womb 
was  retroverted,  though  it  was  much  smaller  than  before.  At 
the  end  of  rather  more  than  three  years  she  again  came  under 
my  notice,  having  in  the  interval  miscarried  several  times  at  an 
early  period  of  pregnancy.  Her  uterus  was  still  retroverted,  and 
the  abortions  were  probably  due  to  the  organ  having  been  bound 
down  by  adhesions  in  this  unnatural  position.  It  had,  however, 
greatly  diminished  in  size,  and  was  now  little  if  at  all  larger  than 
the  healthy  womb. 

Besides  this  form  of  uterine  enlargement  from  defective  involu- 
tion, there  is  another,  occasionally,  though  much  less  frequently 
met  with,  in  which  the  enlargement  of  the  ivomh  takes  place  inde- 
pendent of  previous  pregnancy,  and  is  the  result  of  a  more  genuine 
hypertrofhy.  Cases  of  this  kind,  which  I  have  met  with  exclu- 
sively in  women  who  have  lived  for  a  longer  or  shorter  time  in 
childless  marriage,  present  themselves  in  most  instances  without 
an}'  definite  clue  to  their  history ;  a  sense  of  weight  in  the  pelvis, 
pain  usually  of  a  burning  character,  and  hemorrhages  having 

1  Dr.  Matthe-ws  Duncan  has  described,  in  Edinhiirqh  Monthly  Journal,  .June 
1856,  p.  1057,  some  cases  in  which  he  believes  that,  independently  of  any  disease 
of  the  uterus,  there  existed  a  state  of  unnatural  patency  of  the  Fallopian  tube  on 
one  side,  admitting  of  the  passage  of  the  uterine  sound  along  it  for  several  inches. 
Such  a  state,  however,  which  is  probably  one  of  considerable  rarity,  is  not  likely 
to  be  confounded  with  instances  of  enlargement  of  the  womb  itself,  since  an  ordi- 
nary-vaginal  examination  would  at  once  inform  us  whether  or  no  that' organ  is 
larger  and  heavier  and  less  movable  than  natural,  conditions  which  were  absent 
in  the  instances  that  Dr.  Duncan  relates  of  dilated  Fallopian  tube. 


FROM     DEFECTIVE    INVOLUTION.  87 

gradually  come  on,  and  forced  themselves  by  their  slowly-increas- 
ing severity  (sometimes  not  till  after  the  lapse  of  years)  on  the 
patient's  notice.  Excessive  or  intemperate  sexual  intercourse  does 
not  produce  it,  though  that  leads  to  its  own  train  of  evils;  but 
there  has,  in  many  instances,  seemed  to  be  good  reason  for  asso- 
ciating the  condition  with  th6  imperfect  performance  of  that  func- 
tion, and  sometimes  the  evidences  of  this  being  the  case  have  been 
conclusive. 

Some  years  ago  I  saw  a  lady,  aged  forty-three,  who,  during 
thirteen  years  of  married  life,  had  never  been  pregnant.  She  had 
always  menstruated  painfully,  and  rather  profusel}-;  and  both 
these  ailments  had  by  degrees  grown  worse,  and  this  especially 
during  the  last  few  months.  She  complained  of  sense  of  weight 
and  dragging  immediately  on  making  any  attempt  to  walk,  and 
induced  even  by  remaining  long  in  the  sitting  posture.  The  bowels 
were  constipated,  and  defecation  was  difficult.  Menstruation  was 
very  profuse,  accompanied  by  discharge  of  coagula,  while  at 
uncertain  intervals  during  its  continuance  most  violent  paroxysms 
of  uterine  pain  came  on.  On  examination,  the  enlarged  uterus 
was  distinctly  felt  above  the  symphysis  pubis  as  large  as  the 
doubled  fist,  and  per  vaginam  the  whole  organ  was  found  much 
enlarged  and  much  heavier  than  natural ;  the  cervix  large  and 
thick,  but  not  indurated ;  the  os  uteri  small  and  circular ;  and  the 
hymen  was  entire. 

Rest,  attention  to  the  bowels,  local  leeching  every  fortnight, 
continued  for  several  months,  together  with  the  careful  employ- 
ment of  preparations  of  iron  combined  with  small  doses  of  the 
iodide  of  potassium,  were  followed  by  the  gradual  suppression  of 
the  menorrhagia,  by  great  diminution  of  all  the  patient's  painful 
sensations,  and  by  marked  lessening  of  the  size  of  the  uterus.  I 
believe,  too,  that  in  most  cases,  a  similar  plan  of  treatment,  coupled 
of  course  with  temporary  separation  from  her  husband's  bed,  will 
be  followed  by  improvement,  and,  if  long  enough  persevered  in, 
by  complete  recovery  of  the  patient.  In  the  instance  I  have  just 
related,  the  patient's  age  and  the  number  of  years  that  she  had 
already  been  married  put  aside  all  question  as  to  the  possibility, 
or  at  least  the  probability,  of  her  becoming  pregnant.  A  some- 
what similar  state  of  things  is,  however,  sometimes  observed  in 
younger  women,  and  within  a  few  months  after  marriage ;  and 
the  state  of  the  husband's  virile  powers  will  be  a  point  concerning 
which  it  will  be  your  duty  in  these  cases  to  make  some  inquiry, 
and  perhaps  even  to  offer  some  suggestion.  You  must  bear  iu 
mind  that  not  only  the  old  rake,  but  also  the  hard  student,  or  the 
man  who  has  long  led  a  life  of  perfect  chastity,  often  has  but 
feeble  sexual  power.  Such  a  person  marries :  anxiety  for  children, 
or  some  of  those  complex  feelings  which  at  once  come  into  play 
in  all  matters  concerning  the  generative  functions,  lead  him  to 
over-frequent  attempts  at  sexual  congress.  The  act  is  incom[iletely 
performed  ;  nervous  apprehension  leads  to  its  still  more  frequent 
attempt  and  its  more  incomplete  performance;  and,  unless  l)y 


88        HYPERTROPHY  OF  THE  CERVIX  UTERI. 

good  fortune  pregnane}-  has  taken  plaee  very  soon  after  marriage, 
a  condition  of  permanent  uterine  congestion  is  induced,  wliicli 
leads  to  hypertrophy  of  the  organ,  and  the  wife  becomes  as  inapt 
for  conception  as  the  husband  is  for  procreation.  But  I  have  said 
enough  concerning  a  matter  which  I  would  gladly  have  left  un- 
noticed; 3'our  own  good  sense  will  suggest  to  you  what  advice  to 
give,  and  your  good  taste  Avill  dictate  to  you  how  best  to  give  it. 

Over  and  over  again  in  the  course  of  these  Lectures,  I  shall 
have  to  speak  of  hypertrophy  of  the  uterus  as  a  secondary  result 
of  many  other  ailments  of  the  organ,  and  as  greatly  increasing 
the  difficulty  of  their  cure.  If  fibrous  tumors  form  within  its 
substance,  the  uterus  increases  in  size  ;  and  this  in  a  measure 
proportionate  to  the  intimacy  of  the  relations  between  the  foreign 
body  and  the  tissue  of  the  womb.  If  the  organ  sinks  lower  down 
than  natural,  the  result  of  .the  unaccustomed  irritation  to  which 
it  thereby  becomes  exposed  is  to  produce  its  enlargement,  and 
thus  to  increase  the  difficulty  of  cure  of  the  prolapse.  In  short, 
whenever  the  uterus  is  exposed  to  unusual  irritation,  it  increases 
in  size  ;  not  necessaril3%  nor  I  believe  generally,  as  the  result  of 
inflammation,  but  because  the  organ  is  composed  of  formative 
material,  which  excitement  of  any  kind  will  call  into  active  de- 
velopment, though  it  is  only  under  the  stimulus  of  pregnancy 
that  development  goes  on  to  an}'  useful  end,  or  attains  its  full  per- 
fection. 

There  still  remains  one  form  of  simple  uterine  Tiy^pertro'pliy  to 
which  I  must  refer  before  passing  on  to  other  subjects.  It  is  one 
in  which  the  enlargement  is  limited  to  the  neck  of  the  womb,^  and 
sometimes  even  involves  only  one  lip,  generally  the  anterior.  In 
the  latter  case  it  is  usuall}^  consequent  on  childbearing,  and  per- 
haps is,  strictly  speaking,  rather  a  result  of  a  partial  deficiency  of 
involution  of  the  uterus,  than  the  etfect  of  a  genuine  hypertro- 
phy of  the  part.^  AVhen  affecting  the  whole  of  the  cervix,  it  has, 
however,  not  appeared  to  be  traceable  to  any  such  cause,  since  I 
have  met  with  it  not  only  in  sterile  women,  but  even  in  those 
who  were  unmarried.  The  ailment  seems  to  consist  of  simple 
overgrowth  of  the  part,  the  neck  of  the  womb  being  in  all  re- 
spects healthy  to  the  touch,  and  the  os  uteri  free  from  any  trace 
of  disease.  The  chief  increase  is  in  length,  the  portio  vaginalis, 
instead  of  being  half  or  three-Cjuarters  of  an  inch  long,  measur- 
ing an  inch  and  a  half,  or  two,  or  even  three  inches.  In  those  in- 
stances in  which  the  elongation  of  the  cervix  is  most  considera- 
ble, the  uterus  sinks  down  in  the  pelvic  cavity,  so  that  the  os  uteri 

1  Tliou2;h  noticed  before  by  continental  writers,  Dr.  Evory  Kennedy  was  the 
first  in  this  country  to  call  attention  to  this  aflection,  in  a  paper  published  in  the 
Dublin  Medical  Journal  for  1838. 

2  There  are  two  other  forms  of  hypertrophy  of  the  cervix  uteri  which  I  shall 
consider  hereafter ;  one  in  which  the  elongation  of  the  neck  of  the  womb  is  a  sec- 
ondary result  of  prolapsus  of  the  vagina  :  the  other  in  which  the  hyjicrtrophy  is 
limited,  or  nearly  so,  to  the  mucous  membrane,  and  in  wliich  the  outgrt)wth  as- 
sumes the  form  of  a  polypus,  and  has  been  described  under  that  name.  See  the 
Lectures  on  Prolapsus  and  on  Polypus. 


HYPERTROPHY  OF  THE  CERVIX  UTERI.         89 

sometimes  comes  to  lie  just  within  the  orifice  of  the  vulva,  or 
even  projects  beyond  it,  giving  rise  to  many  of  the  symptoms  of 
prolapsus,  and  being  often  taken  for  it  by  the  patient. 

The  symptoms,  as  just  mentioned,  are  those  of  prolapsus,  and 
consist  of  a  sense  of  weight  and  bearing  down,  aggravated  by  any 
exertion,  and  increased  also  during  the  increased  afflux  of  blood 
towards  the  pelvis  at  each  menstrual  period.  The  condition  pre- 
sents also  a  mechanical  impediment  to  sexual  intercourse,  and 
once  or  twice  discomfort  in  the  act  has  been  the  patient's  chief 
reason  for  applying  for  relief.  I  believe  the  state  also  to  be  an  oc- 
casional cause  of  sterility,  probably  from  the  male  organ  not  com- 
ing into  contact  with  the  os  uteri,  and  from  the  consequent  difii- 
culty  in  the  access  of  the  fecundating  fluid  to  the  womb.  For 
this  eftect,  however,  to  be  produced,  the  hypertrophy  must  needs 
be  considerable. 

I  know  no  cure  for  this  aflPection,  except  the  removal  of  a  por- 
tion of  the  superfluous  growth.  But  as  the  condition  is  one  pro- 
ductive of  inconvenience  rather  than  of  serious  evil,  and  as  the 
removal  of  a  portion  of  the  cervix  uteri  is  by  no  means  devoid  of 
risk,  it  is  the  wiser  course  to  leave  the  smaller  degrees  of  hyper- 
trophy without  interference.  Even  though  the  desire  of  children 
should  prompt  your  patient  to  submit  to  it,  I  should  advise  you 
to  be  very  guarded  in  the  promises  you  make  with  reference  to 
this  point,  for  it  is  quite  possible  that  there  may  be  some  deeper 
seated  reason  for  the  woman's  sterility,  one  which  no  mechanical 
proceeding  can  remedy. 

If  the  operation  is  determined  on,  the  patient  lying  on  her  back, 
and  having  been  brought  under  the  influence  of  chloroform,  the 
uterus  may  readily  be  drawn  down  with  hooks,  and  a  portion  of 
the  cervix  removed  by  a  pair  of  curved  blunt-pointed  scissors,  or 
by  means  of  the  ecraseur.  The  latter  instrument  seems  to  afibrd 
a  complete  guarantee  against  that  formidable  hemorrhage  so  ex- 
tremely diflicult  to  control  by  ice,  or  by  styptics,  or  even  by  the 
most  careful  plugging  of  the  vagina,  which  used  to  form  one  of 
the  great  hazards  of  the  operation.^  The  recollection  of  this 
accident  on  tvvo  occasions  made  me  shrink  from  running  the  same 
risk  again  ;  but,  during  my  connection  with  St.  Bartholemew's 
Hospital,  Mr.  Paget  removed  from  a  patient  of  mine,  by  means 
of  the  ecraseur,  a  portion  of  an  hypertrophied  cervix  uteri,  an  inch 
and  a  half  long,  by  five  inches  in  circumference,  and  which 
w^eighed  an  ounce  and  a  half,  without  the  loss  of  a  single  drop  of 
blood.  The  issue  of  this  case,  however,  was  not  favorable,  for 
death  from  peritonitis  occurred  fifteen  days  afterwards,  an  acci- 
dent to  which  the  patient  was  perhaps  the  more  exposed  in  conse- 
quence of  the  presence  of  a  large  fat  cyst  of  the  ovary.  The  cyst 
did  not  indeed  appear  to  have  been  the  point  of  dcjnirture  of  the 
mischief,  though  its  existence  would  have  been  regarded  as  com- 

i  With  reference  t'o  which,  sec  the  remarks  by  M.  Pauly,  at  page  473  of  his 
Maladies  de  VUtei-us,  &c.,  8vo.,  Paris,  1836. 


90  ACUTE  INFLAMMATION  OF  UTERUS. 

pletel}'-  contrainclicatiHg  any  interference  with  the  womb  had  not 
the  constant  protrusion  of  the  cervix  beyond  the  external  parts  been 
the  occasion  of  extreme  discomfort,  and  ahnost  prevented  tlie  pa- 
tient sitting  down.  Though  not  a  frequent  result  of  amputation  of 
the  neck  of  the  womb,  peritonitis  is  still,  as  even  Lisfranc's  cases 
show,  a  danger  by  no  means  to  be  lost  sight  of.  It  must  remain 
for  further  observation  to  determine  whether  the  risk  of  its  su- 
pervention is  increased  by  the  substitution  of  the  elow  operation 
with  the  ecra^eur  for  the  quick  amputation  of  the  cervix  with  a 
sharp  cutting  instrument. 

From  the  study  of  simple  errors  of  nutrition,  leading  to  the  in- 
creased growth  of  an  organ,  tlie  transition  is  easy  to  the  examina- 
tion of  the  eftect  produced  on  it  by  inflammation.  In  the  case  of 
the  uterus,  however,  there  are  many  circumstances  which  render 
this  study  peculiarly  difficult.  Though  we  regard  it  as  a  single 
organ,  it  is  yet  made  up  of  parts,  differing  widely  in  structure  and 
in  function,  and  having  very  different  tendencies  to  disease,  while 
these  tendencies  vary  at  different  times  according  as  the  highest 
functions  of  the  sexual  organs  have  been  recently  exercised  or 
have  never  been  called  into  activity,  or  as  the  period  for  their  per- 
formance has  already  passed.  Moreover,  the  evidence  of  patho- 
logical anatomy,  wdiich  corrects  so  many  errors  in  other  depart- 
ments of  medical  inquiry,  is  little  available  in  the  case  of  diseases, 
which,  like  the  inflammatory  affections  of  the  unimpregnated 
womb,  hardly  ever  lead  to  a  fatal  issue ;  so  that  we  are  in  constant 
danger  of  mistaking  pseudo-morbid  appearances  for  serious  alter- 
ations, or  of  exaggerating  the  importance  of  real  changes  of  struc- 
ture. Besides,  the  office  of  the  uterus  in  the  unimpregnated  con- 
dition is  so  humble,  and  its  functions  are  so  few,  that  there  must 
needs  be  great  sameness  in  the  symptoms  which  attend  upon  its 
disorders;  and  disturbance  of  menstruation,  increase  or  alteration 
of  the  naturally  scanty  secretion  furnished  by  its  mucous  mem- 
brane, are  alike  met  wath  in  the  most  diverse  affections.  Our 
means  of  examining  the  condition  of  the  womb  are  also  very  im- 
perfect, compared  with  those  that  we  possess  for  investigating  the 
state  of  other  organs  ;  and  hence  the  question  often  arises,  whether 
the  signs  of  disease  which  we  discover  are  the  cause  of  the  symp- 
toms, or  whether  they  are  the  index  of  other  and  more  important 
changes,  or  whether  they  are  neither  the  one  nor  the  other,  but 
mere  casual  concomitants  of  graver  ailments,  concerning  whose 
nature  and  degree  we  can  from  them  deduce  no  conclusion. 
From  these  circumstances  it  has  arisen,  that  the  inflammatory 
diseases  of  the  uterus  have  been  and  still  are  the  subject  of  con- 
flicting opinions,  that  much  of  what  may  seem  to  me  to  be  true 
concerning  them  will  be  unavoidably  at  issue  with  what  is  taught 
by  others,  and  that,  hereafter,  your  own  experience  may  lead  you 
to  conclusions  difl'ering  on  many  points  from  both. 

Before  entering  on  debatable  ground,  however,  I  may  say  a  few 
words  concerning  acute  inflammation  of  the  unim*pregnated  uterus, 
an  ailment  universally  admitted  to  be  of  rare  occurrence.   I  have, 


ACUTE     INFLAMMATION     OF    UTERUS.  91 

however,  seen  it  come  on  with  great  severity  in  the  course  of 
gonorrhoea,  and  believe  that  not  only  in  this  case,  hut  also  in  the 
generality  of  instances,  the  inflammation  begins  in  the  interior  of 
the  womb,  whence  it  extends  outwards,  though  it  involves  the 
muscular  substance  of  the  uterus  to  a  mucb  less  degree  than  its 
lining  membrane.  The  tendency  indeed  of  inflammation  of  the 
uterine  mucous  membrane  to  extend  along  the  Fallopian  tubes, 
and  to  attack  the  peritoneum,  is  much  stronger  than  to  affect  the 
substance  of  the  organ  ;  and  though  abscesses  sometimes  form  as 
a  secondary  result  of  the  disease,  they  are  yet  almost  always  situ- 
ated in  the  pelvic  cellular  tissue,  or  within  the  folds  of  the  broad 
ligament,  and  scarcely  ever  in  the  uterine  wall  itself 

The  affection  is  not  only  infrequent  in  its  occurrence,  but  it  is 
still  rarer  for  it  to  endanger  life,  and  the  only  instance  which  I 
have  seen  after  death  of  the  unimpregnated  uterus  in  a  state  of 
acute  inflammation,  was  in  the  case  of  a  lady  who  died  of  peritonitis, 
for  the  supervention  of  which  no  cause  could  be  assigned  during 
her  lifetime.  On  examination,  however,  her  uterus  was  found  to 
be  much  enlarged,  and  a  fibrous  tumor  of  the  size  of  a  hen's  egg 
was  imbedded  in  its  posterior  wall.  Both  the  tumor  and  the 
thickened  uterine  walls  were  of  a  bright  rose-red  tint,  and  pre- 
sented a  remarkable  degree  of  succulence.  The  cavity  of  the  organ 
was  dilated,  and  contained  at  least  an  ounce  of  pus,  which  seemed 
to  be  retained  within  it  by  the  flexure  of  the  body  upon  the  neck 
of  the  organ,  while  its  lining  membrane  had  exactly  the  appear- 
ance of  bright  red  velvet,  though  it  afterwards  quite  lost  that 
character  by  long  immersion  in  spirit. 

I  have  referred  to  the  extension  of  gonorrhoea!  imflammation 
as  one  cause  of  the  affectjon;  sudden  suppression  of  the  menses 
may  likewise  produce  it,  as  also  may  unaccustomicd  and  intem- 
perate sexual  intercourse ;  while,  after  one  attack,  the  uterus  is 
often  left  in  a  condition  in  which  comparatively  slight  causes  will 
suffice  to  produce  it.  The  sym[)toms  by  which  it  is  attended  are 
a  sense  of  pain  and  weight  in  the  pelvis,  with  a  feeling  of  heat  or 
throbbing,  and  much  tenderness  over  the  tubes.  The  pain  extends 
down  the  thiglis,  is  aggravated  by  exertion,  by  sitting  on  a  hard 
seat,  by  defecation,  or  by  any  attempt  at  sexual  intercourse;  while 
in  this,  as  in  many  other  affections  of  the  uterus,  there  is  often 
more  or  less  irritabilit}'  of  the  bladder  and  desire  to  pass  water 
frequently,  the  urine  being  generally  high-colored,  though  not 
voided  with  pain.  Another  symptom,  not  peculiar  indeed  to  this 
affection,  though  observed  during  its  course  in  a  very  marked  de- 
gree, is  the  occurrence  at  irregular  intervals  of  paroxysmal  exacer- 
bations of  pain  of  very  great  severity,  lasting  for  an  hour  or  two, 
and  then  subsiding,  to  recur  again,  equally  causelessl}-,  in  twelve 
or  twenty-four  hours.  Coupled  with  these  attacks  of  paroxysmal 
j^ain,orsometimesoccurringindependentlyofthenutliough  usually 
associated  with  much  suffering,  are  seizures  of  diarrhoea,  during 
which  the  patient  has  ten  or  twelve  watery  evacuations  in  as  many 
hours,  and  the  bowels  then  become  constipated,  and  remain  so  for 


92  TREATMENT    OF 

two  or  three  clays.  At  the  commencement  of  the  attack  there  is 
no  vaghial  discharge,  but  in  a  day  or  two  an  abundant  puriform 
or  sero-purulent  secretion  is  poured  out,  often  offensive  to  the 
smell,  and  not  infrequently  slightly  tinged  with  blood.  On  exam- 
ination per  vaginam  there  is  always  increased  heat  of  the  parts, 
with  tenderness  amounting  to  severe  pain  on  touching  the  uterus, 
while  the  vessels  of  the  cervix  may  be  felt  pulsating  with  great 
force,  and  the  uterus  is  found  heavier  than  natural,  and  in  many 
instances  obviously  increased  in  size.  The  tenderness  of  the  organ 
has  always  led  me  to  abstain  from  any  attempt  at  measuring  it  by 
means  of  the  uterine  sound,  but  I  can  readily  believe  the  state- 
ment of  the  late  Professor  Kiwisch,  who  states  that  he  has  found 
its  cavity  from  six  to  ten  lines  longer  than  natural.^ 

The  amount  both  of  constitutional  disturbance  and  of  local 
suffering  varies  greatly  in  diflerent  cases,  though,  except  when  the 
peritoneum  becomes  afiected,  it  is  unusual  for  the  symptoms  to  be 
60  severe  as  to  warrant  an}-  grave  apprehensions  as  to  the  patient's 
ultimate  recovery.  There  are,  however,  two  other  risks  besides 
that  of  the  occurrence  of  peritonitis,  against  which  it  behoves  us 
to  be  on  the  watch  during  the  whole  course  of  this  affection.  The 
one  is  that  of  the  ovary,  or  the  broad  ligament,  being  attacked  by 
inflammation,  an  accident  very  likely  indeed  to  issue  in  the  forma- 
tion of  abscess ;  the  other  is  of  the  acute  evil  passing  into  a  sub- 
acute or  chronic  stage,  in  which  the  suffering  is  much  less,  but 
the  prospect  of  permanent  cure  less  also;  and  to  this  latter  result 
all  cases  of  acute  uterine  inflammation,  if  let  alone  or  inade- 
quately treated,  seem  naturally  to  tend. 

The  treatment  of  these  cases  is  abundantly  simple,  tlie  indica- 
tions are  very  clear,  and  the  mistakes  which  are  made  seldom 
consist  in  doing  what  is  wrong,  but  ratlier  in  pursuing  the  right 
end  by  inadequate  means.  Some  rules  are  so  simple,  and  the 
necessity  for  them  is  so  obvious,  that  it  seems  almost  superfluous 
to  insist  upon  them.  Rest  in  bed  in  the  horizontal  posture,  a 
simple  diet,  and  antiphlogistic  regimen,  and,  I  scarcely  need  add, 
abstinence  from  sexual  intercourse,  for,  indeed,  that  is  usually  far 
too  painful  to  be  attempted,  are  essential  to  the  patient's  recovery. 
Palliatives,  however,  do  not  suffice  for  the  patient's  cure,  but  the 
inflammation  must  be  at  once  attacked  energetically,  and  deple- 
tion can,  I  believe,  never  be  dispensed  with.  It  is  not,  indeed, 
usuall}'  necessary  to  resort  to  general  depletion,  but  local  bleeding 
is  invariably  indicated,  and  in  spite  of  the  tenderness  of  the  parts, 
which  makes  the  patient  shrink  from  the  introduction  of  the  spec- 
ulum or  of  the  leech-tube,  much  more  relief  is  afforded  by  the 
application  of  four  or  six  leeches  to  the  uterus  itself  than  of  four 
times  that  number  to  the  hypogastrium  or  the  groins.  Still,  when- 
ever the  constitutional  disturbance  is  considerable,  or  the  local 
suflering  very  severe,  I  think  it  will  be  your  wiser  course  to  take 
a  small  quantity  of  blood  from  the  arm  before  you  have  recourse 

1  Klinische  Vortrdge,  &c.,  1st  vol.,  4th  edition,  Prague,  1854,  p.  578,  I  249. 


ACUTE    INFLAMMATION     OF     UTERUS.  93 

to  local  bleeding.  I  dare  say  you  may  have  seen  the  application 
of  leeches  to  the  abdonaen  appear  to  aggravate  the  symptoms  in 
one  case  of  peritonitis  while  it  entirely  removed  them  in  another, 
and  may  have  found  on  inquiry  that  in  the  latter  case  the  leeching 
had  been  preceded  by  general  bleeding,  while  in  the  former  an 
attempt  had  been  made  to  employ  local  depletion  as  a  substitute 
for  it.  Just  the  same  thing  I  have  observed  in  cases  of  uterine 
inflammation,  and  have  known  the  application  of  leeches  to  the 
womb  induce  a  paroxysm  of  almost  intolerable  suffering,  though 
tlie  same  measure  would  have  relieved  a  less  severe  attack,  and 
even  in  that  very  instance  perfected  the  patient's  cure  after  general 
bleeding  had  been  employed.  In  any  case  in  which  you  find 
severe  pain  coming  on  during  the  application  of  leeches  to  the 
uterus,  I  would  advise  you  to  remove  the  leeches,  and  to  withdraw 
the  tube  as  soon  as  possible.  A  perseverance  in  the  attempt  will 
issue  only  in  a  violent  attack  of  pain.  In  any  case,  too,  in  which 
violent  pain  has  been  induced  by  local  depletion  from  the  uterus, 
it  is  expedient  not  to  venture  on  it  again  soon,  but  to  substitute 
for  it  the  application  of  four  or  six  leeches  to  the  anus,  which 
draw  much  more  blood,  and  afford  far  more  effectual  relief  to  the 
organ  than  double  the  number  applied  to  the  hypogastrium,  or  to 
the  groins. 

After  depletion,  the  tepid  hip-bath  and  anodynes  are  the  reme- 
dies on  which  we  must  mainly  rely.  I  will  not  now  repeat,  with 
reference  to  the  comparative  merit  of  difterent  remedies  of  this 
class,  the  remarks  which  I  made  when  speaking  about  dysnienor- 
rhoea,  but  there  is  one  very  serviceable  medicine,  belladonna, 
that  I  did  not  then  mention.  It  is  well,  as  the  strength  of  the 
extract  varies  considerably,  to  begin  with  a  small  dose,  as  a  sixth 
or  a  quarter  of  a  grain,  in  combination  with  three  grains  of  camphor, 
and  to  repeat  it  every  four  hours,  increasing  the  dose  if  no  inju- 
rious effect  is  produced  by  it.  Another  means  of  alleviating  pain, 
which  in  cases  of  this  description  has  sometimes  proved  extremely 
useful,  consists  in  the  application  of  a  linseed  poultice,  into  which 
an  ounce  of  laudanum  has  been  stirred  while  it  was  mixing,  and 
this,  if  covered  over  with  oiled  silk  or  gutta-percha,  as  all  poul- 
tices should  be,  will  keep  warm  for  many  hours,  and  afford  much 
of  the  ease  which  a  dose  of  opium  would  procure,  without  its  un- 
pleasant consequences. 

That  irritable  state  of  the  bowels  which  gives  rise  to  occasional 
attacks  of  diarrhoea  is  best  controlled  by  small  doses  of  Ilydrarg. 
c.  Creta  and  Dover's  powder  twice  a  day,  while  the  attacks  them- 
selves, as  well  as  the  paroxysms  of  uterine  pain,  are  most  speedily 
arrested  by  opiate  enemata. 

It  is  not  possible  to  lay  down  any  rule  as  to  the  repetition  of 
depletion  ;  or  as  to  the  extent  to  which  such  bleeding  must  be 
carried;  since  these  questions  must  in  each  case  be  determined  by 
the  urgency  of  the  symptoms.  If  the  pain  be  seated  in  one  or 
other  iliac  region,  and  still  more  if  there  be  any  distinct  swelling 
or  even  a  sense  of  fulness  in  that  situation,  it  may  be  assumed 


94    INFLAMMATORY  AFFECTIONS  OF  THE  UTERUS. 

that  the  ovary  has  become  the  seat  of  inflammation,  and  leeches 
must  then  be  applied  externally  to  the  number  of  eight  or  twelve, 
and  repeated  once  or  twice  at  intervals  of  a  day  or  two,  till  all 
acute  pain  and  all  considerable  tenderness  have  disappeared. 
Afterwards,  the  application  of  a  succession  of  small  blisters  over 
the  aftected  part  has  seemed  to  me  very  useful  in  removing  all  pain 
and  tenderness,  and  has,  I  believe,  the  further  good  effect  of  reduc- 
ing the  size  of  the  enlarged  ovary.  With  the  same  view  I  have 
sometimes  employed  an  ointment  of  six  drachms  of  mercurial  oint- 
ment, two  scruples  of  camphor,  and  two  drachms  of  extract  of 
belladonna,  which  is  rubbed  upon  the  aftected  side  twice  a  day ; 
though  usually  I  confine  the  use  of  mercurial  remedies  to  cases 
where  the  ailment  seems  altogether  passing  into  a  chronic  state, 
in  which  permanent  enlargement  of  the  womb  and  induration  of 
its  tissue  are  apt  to  supervene.  In  these  circumstances  a  carefully 
conducted  mild  mercurial  course  is  often  very  beneficial,  the 
bichloride  of  mercury  being  preferable  to  other  preparations  of 
this  drug,  from  its  not  readily  irritating  the  bowels  or  affecting 
the  gums,  and  from  its  being  quite  compatible  with  the  generally 
tonic  plan  of  treatment  wdiich  the  patient's  state  usually  requires. 
In  conclusion  two  other  remarks  may  be  made.  The  first  is 
that  a  considerable  degree  of  uterine  tenderness  is  often  left  behind 
for  many  weeks  whenthe  organ  has  been  the  seat  of  inflammation, 
and  this  not  infrequently  renders  sexual  intercourse  very  painful, 
sometimes  almost  impossible.  This  does  not,  however,  warrant 
anxiety,  for  it  tends  by  degrees  to  disappear ;  and  with  this  as- 
surance you  must  comfort  your  patient.  The  other  is,  that  you 
cannot,  after  an  attack  of  uterine  inflammation,  watch  your  patient 
too  carefully  during  the  next  one  or  two  menstrual  periods.  It  is 
at  these  seasons  of  congestion  of  the  sexual  organs  that  the  great 
danger  exists  of  the  fire,  which  perhaps  was  merely  smouldering, 
being  rekindled ;  while  if  your  patient  passes  safely  through  that 
process,  you  may  feel  confident  that  not  only  the  recent  evil  is 
removed,  but  also  that  no  ill  consequences  have  remained  behind. 


LECTURE    VII. 

INFLAMMATORY  NATURE  OF  THE  UTERUS. 

Chronic  Inflammation.  Discrepancies  of  opinion  as  to  its  frequency ;  influence 
of  invention  of  speculum  on  opinion  with  reference  to  it.  Conflicting  views 
as  to  frequency  of  primary  uterine  ailment ;  reasons  for  taking  aflSrmative  side 
of  question. 

Theory  of  dependence  of  almost  all  ailments  on  Inflammation  of  Cervix  and  Ulcera- 
tion of  Os.  Character  of  ulcerations  described.  Influence  of  this  opinion  on 
practice;  its  correctness  discussed,  and  reasons  for  rejecting  it.  Injurious 
nature  of  practice  to  which  the  opinion  leads,  pointed  out  and  explained. 

From  the  comparatively  rare  affection,  acute  inflammation  of 
the  unimpregnated  uterus,  which  occupied  our  attention  at  the 


INFLAMMATORY    AFFECTIONS     OF    THE    UTERUS.  95 

last  lecture,  we  pass  by  a  natural  and  easy  transition  to  the  study 
of  cases  in  which  inflammation  of  a  more  chronic  character  attacks 
the  organ,  or  is  left  behind  after  the  subsidence  of  active  disorder. 
Some  twenty  years  ago,  tliis  subject  also  might  have  been  treated 
briefly,  and  have  been  dismissed  speedily ;  but  at  the  present  day 
it  may  not  be  so  passed  over.  Inflammation  of  the  uterus  is  now 
regarded  by  many  writers  as  the  most  frequent  of  all  diseases  of 
the  organ,  and  its  consequences  as  so  far-reaching  that  tliey  may 
persist  for  many  years,  disturbing  its  functions,  altering  its  struc- 
ture, and  outlasting  in  their  ill  effects  even  the  period  of  sexual 
vigor.  This  opinion,  too,  which  tends  to  bring  about  a  complete 
revolution  in  theory  and  practice  concerning  uterine  ailments,  is 
entertained  by  persons  whose  authority  is  entitled  to  such  weight, 
is  enforced  by  arguments  which  seem  so  plausible,  and  supported 
by  an  appeal  to  such  large  experience,  that  if  it  do  not  at  once 
compel  our  acquiescence,  at  least  it  cannot  be  rejected  without 
much  consideration  and  careful  examination. 

Unwilliiiigly,  therefore,  I  find  myself  compelled  to  quit  that 
simple  exposition  of  generally  received  truths  which  is  the  main 
object,  and  constitutes  the  chief  utility  of  elementary  teaching,  to 
place  before  you  opposing  views  and  conflicting  statements,  and 
to  point  out  to  you  the  reasons  why  this  opinion  appears  to  me 
erroneous,  and  the  practice  founded  on  it  unsound. 

This,  however,  is  neither  a  very  short  nor  a  very  easy  task.  I 
cannot  even  enter  on  it  without  first  asking  you  to  look  back  with 
me  to  the  state  of  knowledge  concerning  the  structure,  functions, 
and  diseases  of  the  uterus  some  thirty  or  forty  years  ago.  It  is 
only  by  a  just  appreciation  of  the  state  of  science  then,  that  you 
will  be  able  to  understand  how  its  recent  increase  has  yet  left 
room  for  such  wide  discrepancies, of  opinion;  how  one  discovery 
overrated,  and  another  undervalued,  may  possibly  for  a  time  have 
ministered  to  the  furtherance  of  error  rather  than  to  the  advance 
of  truth ;  or  at  least  may  have  mingled  them  together  in  a  confu- 
sion which  we  need  additional  liglit  to  enable  us  to  disentangle. 

So  lately  even  as  thirty  years  ago,  neither  was  the  structure  nor 
were  the  functions  of  the  sexual  organs  at  all  correctly  understood. 
The  uterus,  it  is  true,  was  known  to  be  muscular ;  but  neither  the 
process  by  which  its  muscularity  becomes  so  marked  during  preg- 
nancy, while  it  ceases  to  be  clearly  apparent  soon  after  delivery, 
nor  the  intimate  nature  of  its  structure  in  the  virgin  state,  had 
been  the  subject  of  inquiry.  The  interior  of  its  neck  was  seen  to 
be  invested  by  a  membrane  arranged  in  folds,  between  which 
minute  glands  or  follicles  were  present  in  great  abundance,  but 
the  existence  of  a  distinct  lining  membrane  in  its  cavity  was  rather 
inferred  from  the  results  of  observation  in  some  forms  of  disease, 
than  demonstrated  by  anatomical  investigation  in  a  state  of  health. 
Tliough  the  structure  of  the  ovaries  was  in  the  main  understood, 
yet  the  ovarian  ovule  had  not  been  discovered,  and  the  function 
of  the  ovaries  was  supposed  to  be  called  into  exercise  only  under 
the  stimulus  of  sexual  conjrress.     Hence  it  resulted  that  the  im- 


96  SPECIAL    LIABILITY 

port  of  menstruation  continued  to  be  a  riddle  unread ;  all  that 
was  certainly  known  about  it  being  that  it  was  a  function  which 
bore  an  important  though  undefined  relation  to  the  generative 
process. 

When  the  knowledge  of  healthy  structure  and  of  natural  func- 
tion is  defective,  the  knowledge  of  diseased  structure  and  of  per- 
verted function  must  be  imperfect  too.  It  was  assumed  that  an 
organ  of  such  dense  structure  as  the  unimpregnated  uterus  was 
little  liable  to  inflammation  and  its  kindred  processes,  though  in 
some  rare  cases  the  neck  of  the  womb  was  allowed  to  be  their 
seat.  Its  lining  membrane,  supposed  to  be  so  rudimentarj'  in  the 
unimpregnated  state,  was  not  thought  worth  consideration  among 
the  possible  seats  of  disease;  and  leucorrhoeal  discharges,  imag- 
ined to  be  almost  always  furnished  by  the  vagina,  were  usually 
regarded  as  the  consequence  of  the  index  of  general  debility. 
The  diflerent  morbid  growths  were  not  properly  discriminated : 
scirrhus,  a  disease  of  extreme  rarity,  was  assumed  to  be  of  very 
frequent  occurrence ;  and  to  it  were  attributed  almost  ail  chronic 
aflfections  of  the  neck  of  the  womb  attended  by  induration  of  its 
substance  and  increase  of  its  size. 

In  this  state  of  knowledge,  when  observation  must  have  been 
perpetually  clashing  with  preconceived  opinions,  M.  Kdcamier^ 
first  thought  of  employing  an  instrument — the  speculum — for  the 
more  convenient  application  of  local  remedies  to  cancerous  ulcer- 
ations of  the  womb.  Its  use,  however,  was  not  long  confined  to 
this  object;  for  practitioners  found  that  by  means  of  it  they  were 
enabled  to  discover  various  morbid  conditions  of  the  uterus  with 
which  they  were  previously  unacquainted,  and  to  which  it  was  but 
natural  to  attach  importance  as  the  probable  cause  of  many  before 
inexplicable  symptoms.  In  fact,  by  its  means  one  important  ques- 
tion was  speedily  and  decisively  set  at  rest ;  for  leucorrhceal  dis- 
charges were  ascertained  to  be  derived  in  great  measure  not  from 
the  vagina  but  from  the  uterus,  to  be  associated  with  various  dis- 
eased appearances  of  its  orifice,  and  to  be,  sometimes  at  least,  re- 
moved by  diflerent  remedies  directed  to  that  part  and  to  the  neck 
of  the  womb.  So  long  as  the  lining  membrane  of  the  uterine 
cavity  was  supposed  to  exist  in  the  unimpregnated  state  merely  in 
a  rudimentary  condition,  it  was  most  natural  that  an  exaggerated 
importance  should  be  attached  to  the  various  morbid  appearances 
of  the  OS  and  cervix  uteri;  and  so  long  as  the  ovaries  were  believed 
to  be  called  into  activity  only  at  the  time  of  sexual  congress,  it  was 
to  be  expected  that  their  share  in  the  production  of  diseased  phe- 
nomena should  be  rated  very  low.  Ignorance  with  reference  to 
these  points  was  shared  alike  by  the  advocates  of  the  employment 
of  the  speculum  and  by  the  opponents  of  its  use ;  and  in  these 

1  Not  absolutely  first,  however,  according  to  Hennig,  Der  Kntarrh  der  Weibli- 
chen  Geschlichtstheile,  4to.,  Leipzig,  1862,  p.  89;  for  the  suggestion  was  first  made 
by  Bozzini,  in  a  work  published  at  Weimar  iti  1806,  though  the  form  of  his  spec- 
ulum was  such  as  to  deprive  it  of  all  practical  utility. 


OF    UTERUS    TO    DISEASE.  97 

circumstances  their  controversies  were  not  likely  to  lead  to  any 
satisfactory  result. 

We  need  not,  indeed,  wonder  that  the  disputants  on  both  sides, 
thus  imperfectly  furnislied  for  the  debate,  should  have  narrowed 
the  question  to  one  of  details  touching  the  expediency  of  emj)loy- 
ing  an  instrument  which  some  pronounced  to  be  all  important, 
whilst  otliers  denounced  it  as  useless,  mischievous,  and  even  im- 
moral. It  must  be  obvious,  however,  to  us  who  enjoy  the  advan- 
tage of  the  additions  to  physiological  knowledge  which  the  past 
quarter  of  a  century  has  brought  with  it,  that  the  subject  which 
we  have  to  consider  is  one  far  more  extensive  than  the  propriety 
of  adopting  or  rejecting  a  certain  means  of  diagnosis  and  method 
of  treatment;  and  that  it  really  concerns  the  opinion  which  we 
entertain  with  reference  to  the  main  principles  of  uterine  pathology. 
Regarded  in  this  light,  what  might  at  firt^t  have  seemed  a  trivial 
inquiry  at  once  assumes  grave  importance,  and  becomes,  I  think, 
deserving  of  our  most  serious  attention. 

The  constitutional  origin  of  local  diseases  has,  ever  since  the 
time  of  John  Hunter,  engaged,  and  most  deservedly,  the  closest 
attention  of  the  best  practitioners  of  medicine ;  and  with  the  ad- 
vance of  knowledge  we  find  the  sympathies  to  be  wider  and  still 
wider  by  which  the  well-being  of  the  whole  organism  and  that  of 
its  various  parts  are  bound  together.  Illustrations  of  this  fact  have 
abounded  in  the  preceding  Lectures :  and  we  have  seen  how  the 
excess  of  blood,  or  its  deficiency,  or  its  altered  quality,  may  induce 
menorrhagia,  or  may  render  the  menstrual  flow  scanty:  or  how 
other  more  complex  ailments  may  have  a  similar  eftect,  or  may 
even  cause  the  function  to  be  performed  with  an  unusual  amount 
of  sutfering.  But  some  practitioners,  and  those  especially  who 
reject  the  novel  modes  of  investigating  uterine  disease,  and  who 
take  small  account  of  the  facts  which  those  modes  have  either  re- 
vealed or  have  brought  into  greater  prominence  than  heretofore, 
apply  this  explanation  to  almost  all  diseases  of  the  womb,  alleging 
that  uterine  ailment  is  generally  preceded  by  constitutional  de- 
rangement, and  is  mainly  dependent  upon  it,  and  that,  conse- 
quently, treatment  must  be  addressed  principally  to  the  latter  and 
more  subordinately  to  the  former.^ 

There  is  another  view  directly  antagonistic  to  this,  which  regards 
the  uterine  ailment  as  the  primary  and  more  important  in  almost 
every  instance,  and  according  to  which  the  local  disease  is  every- 
thing, the  constitutional  disorder  nothing  else  than  its  necessary 
result.  The  influence  of  these  latter  opinions  is  apparent  in  the 
practice  of  those  who  are  constantly  on  the  look-out  for  a  mechani- 
cal cause  of  dysmenorrhoea,  and  who  frequently  dilate  or  incise 
the  cervix  uteri  for  its  cure,  who  trace  the  gravest  evils  to  slight 
misplacements  of  the  womb,  and  introduce  instruments  into  its 

•  A  scries  of  able  jjiipers  devoted  to  the  exposition  of  this  view,  was  published 
by  l)r.  F.  W.  Mackenzie,  in  vols,  iii  and  iv  of  the  London  Journal  of  Medicine  for 
1851  and  1852. 


98  SPECIAL    LIABILITY 

interior  to  remedy  its  malposition ;  or,  lastly,  who  discover  in 
some  very  small  and  limited  ailment  of  the  mucous  membrane 
of  the  OS  uteri  an  adequate  explanation  of  the  most  varied  and 
most  distant  ills,  and  who  as  sedulously  adopt  as  their  oppo- 
nents studiously  avoid  local  treatment  for  the  cure  of  uterine  dis- 
orders. 

I  shall  presently  have  occasion  to  point  out  to  you  what  seem 
to  me  to  be  the  defects  in  the  latter  view,  but  must  first  call  to  your 
mind  certain  considerations  which  must,  as  it  seems  to  me,  prevent 
us  from  giving  implicit  assent  to  the  former,  since  they  render  it 
probable  that  the  uterus,  more  frequently  perhaps  than  any  other 
organ  of  the  body,  should  be  the  seat  of  certain  forms  of  local 
ailment,  and  should  consequently  require  the  frequent  employ- 
ment of  local  treatment. 

It  would  not  be  easy  to  imagine  a  state  of  things  more  favora- 
ble to  the  occurrence  of  ailments  dependent  on  venous  congestion, 
or  in  which  those  ailments  would  be  more  difficult  to  remove,  or 
more  apt  to  return,  than  is  observed  in  the  case  of  the  uterus  dDring 
the  whole  period  of  activity  of  the  generative  powers.  The  return 
of  blood  from  the  organ,  which  is  rendered  difficult  by  its  situation 
at  the  lower  part  of  the  trunk,  is  still  further  impeded  by  the 
absence  of  valves  from  its  veins ;  while  every  month,  for  several 
days  together,  this  organ  and  its  appendages  are  the  parts  towards 
which  blood  flows  in  superabundant  streams.  During  this  period, 
the  natural  secretion  from  the  uterus  and  Fallojiian  tubes  is  much 
increased;  the  epithelium  covering  their  surface  is  detached,  and 
reproduced  again  and  again  ;  hemorrhage  breaks  out  along  the 
whole  tract, — and  it  is  not  until  this  has  continued  for  some  days 
that  the  congestion  ceases,  and  the  parts  subside  once  more  into 
their  former  state  of  quiescence, — the  uterus  remaining,  however, 
for  a  short  time  heavier,  and  its  tissue  looser,  and  more  abundantly 
supplied  with  blood  than  it  was  before.  I  need  not  stop  to  tell 
how  slight  a  cause  may  protract  this  hemorrhage,  or  how  some 
accident  may  check  it ;  nor  need  I  labor  hard  to  prove  that  in 
either  case  there  nmst  be  a  general  disturbance  of  the  functions 
of  the  organ — a  general  impairment  of  the  health  of  the  individual : 
exhausted  in  the  one  instance  by  loss  of  blood,  broken  down  in  the 
other  by  the  suffering,  both  general  and  local,  which  the  return 
of  the  periodical  excitement  of  the  generative  organs,  unrelieved 
by  their  customary  depletion,  cannot  fail  to  bring  with  it.  In 
what  organ  of  the  body  does  one  find  a  parallel  to  this  series  of 
occurrences  ? 

Again :  the  uterus  is  held  in  its  position  by  supports  which 
allow  to  it  a  large  measure  of  mobility,  and  whose  power  is  gener- 
ally diminished  by  the  very  causes  that  increase  the  weight  of  the 
body  they  have  to  bear.  Hence  it  is  very  apt  to  become  displaced, 
andto  be  displaced  in  a  downward  direction,  or  prolapsed.  And 
such  prolapsus  not  only  brings  with  it  a  variety  of  painful  sensa- 
tions due  to  the  womb  dragging  upon  its  ligaments,  but  the 
moment  the  organ  ceases  to  be  suspended  in  the  pelvic  cavity  it 


OF    UTERUS    TO    DISEASE.  99 

becomes  exposed  to  shocks  of  various  kinds,  to  irritation  from 
sources  from  which  it  was  previously  safe.  The  neck  of  the  womb, 
even  when  that  descent  is  not  very  considerable,  becomes  a  sort 
of  stem  on  which  the  organ  rests  upon  the  floor  of  the  vagina.  In 
this  position  it  is  liable  to  disturbing  causes  almost  numberless; 
sitting,  riding,  exertion  of  any  kind,  the  very  passage  of  the  faeces 
along  the  rectum,  produce  pain,  keep  up  congestion,  and  favor 
that  slow  increase  of  size  which  seldom  fails  to  occur  in  parts  the 
seat  of  long-continued  irritation,  and  which  ofl'ers  one  great  im- 
pediment to  the  cure  of  many  affections  of  the  womb. 

Another  peculiar  and  fertile  source  of  disorders  of  the  womb  is 
furnished  by  the  changes  that  attend  upon  conception  and  partu- 
rition, and  their  frequent  interruption.  With  these  changes,  even 
in  the  healthy  state,  our  acquaintance  is  at  present  too  imperfect 
for  us  to  appreciate  with  accuracy  the  nature  of  the  mischief  that 
may  result  from  their  disturbance.  We  know,  indeed,  many  things 
concerning  these  processes  of  which  our  predecessors  were  ignor- 
ant; but  our  increased  knowledge  is  as  yet  only  sufiicient  to  show 
us  the  difiiculties  of  the  problem,  not  suificient  to  furnish  its  solu- 
tion. The  growth  of  the  pregnant  womb  is  not,  as  it  was  once 
supposed  to  be,  a  mere  increase  in  size  and  unfolding  of  texture 
of  the  muscular  fibres  alread}^  present  there,  but  is  as  much  the 
result  of  a  new  formation  as  is  that  of  the  foetus  contained  within 
it ;  its  tissues  going  through  the  same  development  from  a  rudi- 
mentary condition  to  a  high  organization.  Cells  elongate  into 
caudate  bodies,  these  unite  into  fibrillae,  while  the  mucous  mem- 
brane increases  in  vascularity,  grows  in  thickness,  and  becomes 
developed  into  decidua.  The  small,  dense,  lowlj^-organized  uterus 
becomes  the  large,  vascular,  powerful  muscle  which  we  see  it  to 
be  at  the  end  of  pregnancy ;  when  having  served  as  the  residence 
of  the  foetus,  and  as  the  medium  through  which  it  derived  its  sup- 
port, the  organ  aecomplishes  in  the  act  of  parturition  the  last  of 
that  wonderful  series  of  processes  of  which  for  forty  weeks  it  has 
been  the  centre.  But  even  before  this  period  has  arrived,  indica- 
tions of  decay  have  manifested  themselves  in  the  changes  that  have 
taken  place  in  the  decidua  ;  while  no  sooner  is  the  child  born  than 
all  the  tissues  of  the  woml)  evince  the  commencement  of  similar 
alterations,  which  go  on  with  a  rapidity  such  as  is  observed  in  no 
other*  organ  and  in  no  other  circumstances.  •  The  muscular  fibres 
undergo  fatty  degeneration,  and  to  a  great  extent  disappear;  nerve- 
matter  ceases  to  be  ap[)ar(.'nt  within  the  sheaths  which  had  con- 
tained it,  while  even  the  fibres  of  elastic  tissue  interwoven  with 
the  muscular  substance  of  the  womb  lose  their  distinctness,  or 
become  entirely  absorbed.  The  old  uterus  has  done  its  work  and 
is  removed ;  but  in  the  midst  of  its  decaying  fibres  the  elements 
of  a  new  organ  are  devclo[>ed,  and  the  microscopist  tells  us  of  a 
new  generation  of  spindle-sha[)ed  cells  which  he  can  discover  in 
its  tissue,  just  like  those  which  existed  in  the  organ  l)cf(Me  i»reg- 
naucy  began,  and  which  remain  stationary  at  the  same  low  stage 


100  ALLEGED    IMPORTANCE    OF 

of  formation,  till  in  their  turn  excited  by  impregnation  to  go 
through  higher  phases  of  development. 

In  these  changes  the  body  of  the  uterus,  and  the  lining  of  its 
cavity,  bear  a  far  greater  part  than  either  the  substance  of  its  cervix, 
or  the  mucous  membrane  which  lines  that  canal.  The  mucous 
membrane  of  the  body  only  is  developed  to  the  decidua,  and  it 
alone  is  thrown  off  after  delivery;  the  lining  membrane  of  the  neck 
undergoes  much  slighter  alterations,  and  is  not  deciduous.  It  is 
in  the  body  of  the  uterus  that  its  muscularity  is  most  evident;  firm 
fibro-cellular  tissue  predominates  in  the  cervix,  with  which  are 
interwoven  here  and  there  bundles  of  narrow,  smooth,  muscular 
fibres  ;  and  the  stimulus  of  pregnancy  which  works  such  changes 
in  the  former  situation,  brings  to  pass  far  slighter  alterations  in 
the  latter. 

Though  our  knowledge  is  still  but  imperfect,  we  yet  know  some- 
thing of  the  results  which  often  succeed  to  accidents  that  interrupt 
the  course  of  pregnancy,  and  originate  the  processes  of  degrada- 
tion of  the  uterine  tissue  prematurely  ;  or  which  follow  on  disease 
SHCceeding  to  delivery  at  the  full  period.  Some  of  these  results 
were  pointed  out  to  you  in  the  last  Lecture,  when  I  was  speaking 
of  deficient  involution  of  the  uterus,  and  of  the  evils  that  may 
follow  in  its  train  ;  wdiile  I  referred  to  other  ailments  of  a  some- 
what similar  character  which  may  come  on  independent  of  preg- 
nancy, as  the  consequence  of  some  form  of  irritation  or  excite- 
ment of  the  womb. 

In  nearly  fifty  per  cent,  of  the  patients  who  applied  at  St.  Bar- 
tholomew's Hospital  for  the  cure  of  uterine  ailments  independent 
of  organic  disease,  marriage,  pregnancy,  or  delivery  was  assigned 
as  the  cause  of  the  patient's  symptoms ;  and  it  is,  I  think,  fair  to 
assume  that  in  this  large  proportion  of  cases  the  disorder  was  local 
in  its  origin,  and  that  the  constitutional  affection  was  but  the 
secondary  result  of  its  intensity  or  persistence.  Plausible,  indeed, 
as  the  argument  appears,  that  the  performance  of  functions  for  the 
discharge  of  which  any  organ  is  expressly  constituted  cannot  be 
likely  to  produce  disease  of  that  organ,  you  yet  must  not  forget 
those  peculiarities  of  the  uterus  which  render  it  a  probable  excep- 
tion to  such  a  rule,  while  the  fact  is  also  not  without  its  signifi- 
cance,  that  of  425  applicants  for  the  relief  of  non-organic  uterine 
ailments,  404  were  married  women  or  widows,  and  only  2; I  un- 
married.' 

But  while  I  mention  these  facts  in  order  to  caution  you  against 

1  It  is  not  possible,  from  the  statistics  of  the  out-patient  department  of  a  hospital, 
to  deduce  anything  like  a  correct  estimate  of  the  comparative  frequency  of  difl'er- 
ent  diseases ;  and  the  sources  of  error  are  still  more  numerous  in  the  case  of  any 
department  of  a  hospital  devoted  to  the  cure  of  a  special  class  of  diseases ;  since 
the  more  serious  of  those  affections  are  sure  to  present  themselves  at  it  in  a  very 
undue  proportion.  The  statements  in  the  text,  then,  are  not  intended  to  repre- 
sent the  absolute  frequency  of  primary  uterine  disease,  in  comparison  with  cases 
in  which  the  disorder  of  the  womb  is  secondary  to  constitutional  ailment,  but 
merely  to  guard  against  the  assumption  that  the  uterine  afi'ection  is,  in  almost  all 
instances,  secondary  in  point  of  time  and  subordinate  in  importance. 


INFLAMMATION    AND     ULCERATION    OF    CERVIX.        101 

unflerratiiig  the  frequencj  or  the  importance  of  uterine  ailments  as 
primary  disorders,  it  is  far  from  my  object  to  lead  you  to  supj^ose 
either  that  these  disorders  have  one  invariable  cause,  or  that  they 
are  the  results  of  one  constant  pathological  occurrence.  This, 
however,  or  something  very  like  it,  has  been  maintained  ;  it  has 
been  alleged  that  there  is  an  invariable,  or  almost  invariable  cause 
of  these  symptoms, — that  be  the  remote  occasion  of  them  what  it 
may,  inflammation  and  ulceration  of  the  neck  of  the  ivomh  is  their 
immediate  cause, — that  the  key  to  the  right  understanding  of 
uterine  diseases  is  to  be  found  in  the  correct  appreciation  of  the 
importance  of  this  condition  ;  and  the  cardinal  point  in  their 
treatment  consists  in  the  adoption  of  means  for  its  cure. 

The  ulcerations  to  which  such  important  results  are  attributed 
are  for  the  most  part  mere  superficial  abrasions  of  the  epithelium 
investing  the  lips  of  the  os  uteri,  whose  abraded  surface  is  of  a 
vivid  red  color,  and  finely  granular.  This  granular  appearance 
seems  to  be  due  to  the  papillae  that  beset  the  surface  of  the  uterine 
lips  having  become  denuded  of  their  epithelium;  while  the  larger 
and  more  distinct  granulations,  which  frequently  bleed  readily 
on,  being  touched,  are  these  same  papillre,  not  merely  deprived  of 
their  epithelial  investment,  but  actuality  h3'pertrophied.^  In  other 
cases  in  which  the  absence  of  cpitlielium  is  less  complete,  the 
surface  seems  beset  by  a  number  of  minute,  superficial,  aphthous 
ulcerations,  between  which  the  tissue  appears  healthy,  or  slightly 
redder  than  natural.  The  ulcerations  of  the  os  uteri  seldom  or 
never  present  an  excavated  appearance  with  raised  edges,  as  ulcers 
of  other  parts  often  do  ;  but  either  their  surface  is  smooth,  or  it 
projects  a  little  beyond  the  level  of  the  surrounding  tissue.  They 
are  usually,  but  not  constantly,  of  greater  extent  on  the  posterior 
than  on  the  anterior  lip,  are  sometimes  confined  to  the  former,  but 
very  rarely  indeed  limited  to  the  latter.  They  appear  to  com- 
mence at  the  inner  margin  of  the  os  uteri,  wdience  they  extend 
outwards  ;  and  sometimes,  though  by  no  means  invariably,  the 
short  extent  of  the  canal  of  the  cervix  uteri  wdiich  can  be  brought 
into  view  by  the  speculum,  appears  denuded  of  its  epithelium. 
The  adjacent  parts  of  the  os  uteri  vary  considerabl}^  in  their 
appearance;  sometimes  their  natural  pale  rose  tint  is  preserved 
up  to  the  edge  of  the  abrasion,  wdiich  is  marked  by  a  distinct 
well-defined  line,  while  at  other  times  the  whole  surface  is  of  a 
much  more  vivid  red  than  natural,  and  the  line  of  demarcation 
between  the  abraded  and  the  healthy  surface  is  irregular  and  indis- 
tinct, the  one  encroaching  on  the  other.  The  orifice  of  the  uterus 
is  generally  more  open  than  in  a  state  of  health,  and  the  disappear- 
ance of  the  abrasion,  which  always  takes  place  from  the  periidierj' 
towards  the  centre,  is  accompanied  by  the  gradual  closure  of  the 
previously  patent  orifice.  The  state  of  the  tissue  of  the  os  and 
cervix  varies  ;  sometimes  there  is  a  very  marked  softness  of  the 

1  See  the  account  of  their  microscopic  structure  in  the  chiboratc  work  of  Uennig, 
op.  cit.,  p.  64. 


102  CORRECTNESS    OF    THESE 

parts,  the  condition  resembling  that  of  the  uterus  soon  after  abor- 
tion or  delivery,  while  at  other  times  it  is  much  harder  than  natural ; 
but  it  certainly  is  not  at  all  a  common  occurrence  for  extensive  ab- 
rasion of  the  OS  uteri  to  coexist  with  a  condition  of  the  organ  such 
as  would  seem  healthy  to  the  touch.  The  secretion  from  the  sur- 
face varies  considerably  in  different  cases,  and  the  chief  part  of  the 
leucorrhceal  discharge  from  wdiich  the  patient  sutlers  is  derived 
from  within  the  canal  of  the  cervix,  or  from  the  cavity  of  the  womb, 
not  from  the  abrasion  itself  Still,  in  some  instances,  those  espe- 
cially in  which  the  ulceration  presents  a  very  marked  granular 
character,  the  discharge  derived  from  this  source  alone  is  far  from 
inconsiderable.  The  degree  of  sensibility  which  the  ulcerated  sur- 
face possesses  also  varies  greatly  ;  now  and  then  the  slightest  touch 
is  extremely  painful ;  but  in  the  majority  of  cases,  the  ulcerated 
surface  is  not  more  sensitive  than  the  adjacent  parts,  nor  is  the 
,  neck  of  the  uterus  whose  os  is  abraded  by  any  means  constantly 
more  tender  to  the  touch  than  the  same  part  of  an  organ  entirely 
free  from  that  aflection. 

Such,  then,  are  the  chief  characters  of  the  ulcerations,  abra- 
sions, and  granulations  of  the  os  uteri,  to  which  so  high  a  patho- 
logical import  is  attached  by  some  writers.  It  is  alleged  in  ex- 
planation and  in  support  of  this  opinion,  that  the  mucous  mem- 
brane of  the  cervix  uteri,  by  reason  of  its  vascularity  and  of  the 
abundance  of  mucous  follicles  which  are  embedded  between  its 
duplicatures,  is  extremely  liable  to  inflamation  ;  and  that  this  pre- 
disposition is  still  further  increased  by  the  abundant  afflux  of 
blood  towards  the  neck  of  the  womb,  as  well  as  by  the  position 
of  that  part  of  the  organ  and  its  consequent  exposure  to  irritation 
and  injury  from  various  sources.  This  inflamation  of  the  cervix 
is  said  to  manifest  itself  by  the  secretion  of  an  abundant  albumi- 
nous matter  from  the  cervical  glands,  and  by  the  opening  of  the 
otherwise  closed  os  uteri ;  as  also,  in  by  far  the  greater  number 
of  instances,  by  abrasion  or  ulceration  of  the  os  uteri,  which  usu- 
ally occurs  at  a  very  early  period.  The  cervix  becomes  swollen 
and  congested,  and  it  increases  in  size  ;  but  while  in  some  in- 
stances it  remains  soft  to  the  touch,  even  after  years  of  disease, 
its  substance  becomes  more  frequently  the  seat  of  inflammation, 
lymph  is  effused  into  it,  and  it  is  not  merely  enlarged,  but  indur- 
ated— a  change  which  takes  place  to  a  greater  degree  in  those 
who  have  given  birth  to  children  than  in  the  unmarried  or  sterile. 
The  different  extent  of  the  ulceration  is  the  only  cause  assigiied 
for  the  presence  of  induration  of  the  cervix  in  one  case  and  its 
absence  in  another ;  but  the  relation  of  the  two  conditions  does 
not  seem  to  be  by  any  means  invariable.  The  degree  to  which 
the  ulceration  spreads  appears  also  to  be  uncertain  ;  in  the  gi-eat 
majority  of  cases  it  passes  more  or  less  deeply  into  the  canal  of 
the  cervix,  and  sometimes  occupies  its  whole  extent,  th«  internal 
OS  uteri,  however,  forming  a  barrier  to  its  further  progress,  and 
preventing  almost  invariably  its  extension  into  the  cavity  of  the 
womb.     It  is  then  inflammation,  with  its  attendant  ulceration  of 


OPINIONS    DOUBTFUL.  103 

the  OS  and  the  cervix  uteri,  and  usually  with  consecutive  indura- 
tion of  its  tissue,  to  which,  according  to  these  views,  the  sufler- 
ings  of  the  patients  are  due  ;  and  all  the  varied  disorders  of  the 
uterine  functions — the  pain,  the  leucorrhoea,  the  homorrluiges, 
the  sterility,  or  the  frequently  occurring  ahortions — are  attributed 
to  the  sympathies  of  contiguous  parts  with  that  small  portion  of 
the  womb  which  is  the  seat  of  disease.  Ulceration,  too,  when 
once  it  has  occurred,  is  alleged  to  have  scarcely  any  tendency  to 
heal ;  while  so  long  as  it  remains  there  may  perhaps  be  a  lull  in 
the  patient's  sulferings,  and  some  temporary  mitigation  of  her 
symptoms;  but  there  can  be  no  real  cure  until  the  time  when, 
the  period  of  sexual  vigor  having  expired,  the  organs  which  sub- 
served it  pass  into  a  common  state  of  atrophy  ;  while  cure,  even 
then,  is  uncertain,  and  the  consequences  of  disease  outlast,  by  no 
means  rarely,  the  uses  of  the  part. 

As  uterine  pathology  is  sim[)lified  beyond  expectation  by  the 
discovery  of  an  almost  invariable  cause  of  the  most  diverse  symp- 
toms, so  uterine  therapeutics  also  are  made  easy,  according  to  the 
writers  whose  opinions  I  am  relating,  by  one  remedy  being  found 
almost  always  applicable  for  its  cure,  be  the  duration  of  the  disease 
or  its  severity  what  it  may.  If  the  evil  be  slight,  its  removal 
will  be  speedy;  if  severe,  a  longer  time  will  be  required:  but  to 
modify  the  vitality  of  the  part  by  caustics  is  the  one  unfailing 
indication;  and,  this  accomplished,  the  ulceration  and  the  inflam- 
mation and  its  results  disappear  together,  and  the  sufferings  of 
years  are  thus  almost  infallibly  got  rid  of  in  a  few  weeks,  or  at 
latest  in  a  few  months.  There  are,  indeed,  some  cases  of  slight 
mischief,  which  rest,  antiphlogistic  treatment,  and  vaginal  injec- 
tions, may  cure;  but  these  are  rare.  There  are  also  some  circum- 
stances in  which  the  local  abstraction  of  blood  may  be  of  service; 
but  what  caustics  to  use,  how  often  to  repeat  their  ap[»lication, 
how  to  prevent  or  to  remove  those  inconveniences  which  sometimes 
result  from  their  employment,  are  questions  discussed  as  of  chief 
importance ;  since  to  these  remedies  all  other  local  measures  as 
well  as  general  trejitment  are  but  secondary  and  subservient. 

Having  now  detailed  these  opinions,  and  pointed  out  the  prac- 
tical consequences  which  flow  from  them,  I  nmst  occupy  the 
remainder  of  this  Lecture  in  the  endeavor  to  set  before  you  as 
briefly  as  possible  the  reasons  which  lead  me  to  reject  the  opinions 
as  erroneous,  and  to  caution  you  against  the  practice  which  they 
are  supposed  to  warrant. 

Among  the  arguments  by  which  these  views  have  been  sup- 
ported, is  one  derived  from  the  assumed  greater  vascularit}'  and 
higher  vitality  of  the  cervix  than  of  the  body  of  the  uterus,  and 
its  supposed  consequent  greater  liability  to  become  the  seat  of  in- 
flammatory mischief.  But  not  only  does  a  simple  examination  of 
the  womb  sufiice  to  show  that  blood  is  distributed  in  greater 
abundance  to  the  body  than  to  the  neck  of  tlic  organ,  l)ut  a  con- 
sideration of  the  relative  share  of  the  body  and  of  the  neck  of  the 
womb  in  furnishing  the  menstrual  discharge,  or  in  the  changes 


104  CORRECTNESS    OF    THESE 

which  pregnancy  and  delivery  bring  with  them,  must  lead,  I 
think,  inevitably  to  the  opposite  conclusion.  Nor,  indeed,  with 
reference  to  these  points,  are  we  confined  to  inferential  reasoning, 
but  the  advanced  stage  which  cancerous  disease  of  the  neck  of  the 
womb  not  seldom  readies  before  either  general  illness  or  local 
suffering  betrays  its  existence,  leads  to  the  same  conclusion,  \vhile 
everv-day  observation  has  shown  that  the  cervix  uteri  may  be 
forcibly"  dilated,  may  be  incised,  its  tissue  may  be  burnt  w^ith  the 
strongest  caustics,  or  with  the  hot  iron,  or  portions  of  it  may  be 
removed  with  the  knife,  with  an  impunity  wholly  incompatible, 
as  I  cannot  but  conceive,  with  the  assumption  that  the  part  is  one 
endowed  with  high  vitality  and  delicate  sensibility. 

The  results  of  post-mortem  examinations  have  been  appealed 
to  by  the  opponents  of  these  views  in  order  to  negative,  by  the 
rarity  with  which  ulceration  of  the  os  uteri  was  observed,  the  idea 
of  its  important  share  in  the  production  of  uterine  ailments.  To 
my  thinking,  however,  the  very  frequency  with  which  this  condi- 
tion is  discovered,  furnishes  a  still  more  cogent  reason  for  regard- 
ing it  as  of  comparatively  little  moment.  In  seventeen  out  of 
sixty-five  instances  in  which  I  examined  after  death  the  uteri  of 
women  who  died  of  other  than  uterine  affeptions,  or  in  rather 
more  than  a  fourth  of  the  total  number,  abrasion  or  ulceration  of 
the  OS  uteri  w^as  present.^  But  though  so  often  met  wnth,  this 
ulceration  w^as  usually  very  limited  in  extent,  and  so  superficial  as 
to  be  unassociated  with  changes  in  the  basement  membrane  of  the 
affected  surface,  and  exercising  so  little  influence  on  the  state  of 
the  uterus  in  general  as  to  be  unconnected,  in  a  large  number  of 
instances,  with  changes  either  in  the  interior  of  the  womb,  or  in 
its  substance;  while  induration  of  the  uterine  tissue  and  disease 
of  the  lining  membrane  of  the  womb  were  found  independently 
of  it  or  of  each  other. 

As  far  as  it  goes,  the  evidence  of  anatomical  investigation  appears 
to  me  unexceptionable.  It  shows  the  absence  of  any  necessary 
connection  between  ulceration  of  the  os  and  those  other  changes 
of  the  uterine  tissue  which  have  been  alleged  to  be  dependent  on 
it,  and  suggests  the  probability  that  an  afi'ection  which  was  be- 
tokened by  no  marked  symptom  during  life,  and  is  found  asso- 

^  Table  showing  the  Chief  Results  of  the  Examination  of  Sixty-five  Uteri. 

Uterus  healthj'  in 36 

"     diseased  in   ... .29 

Ulceration  of  os  uteri — 

"         existed  alone  in     .         .         .         .         .         .  .         .11 

"         with  diseased  lining  of  uterus  in  .         .         .  .         .3 

"        with  induration  of  walls  of  uterus  in  .         .  .         .    3 17 

Induration  of  walls  of  uterus,  without  ulceration  of  os,  .         .         .5 

Disease  of  lining  of  uterus,  without  ulceration  of  OS,  ...       7 

Total  of  diseased  uteri,      .         .         .         .         .29 
For  the  exact  particulars  of  most  of  these  examinations,  as  well  as  for  the  details 
of  the  argument  condensed  in  this  lecture,  I  must  refer  to  my  Croonian  Lectures, 
On  the  Pathological  Importance  of  Ulceration  of  the  Os  Uteri.     8vo.    London,  1854. 


OPINIONS    DOUBTFUL.  105 

ciatcd  with  no  important  alteration  after  death,  must  itself  be  of 
no  great  moment. 

All  additional  reason  for  suspecting  that  the  importance  of  this 
condition  has  been  overrated,  is  furnished  by  what  we  observe  in 
cases  of  prolapse,  or  procidentia  of  the  womb.  From  tlic  una- 
voidable irritation  to  wliich  it  is  exposed,  the  neighborhood  of  the 
OS  uteri  becomes  in  these  circumstances  almost  invariably  ulcer- 
ated, and  this  ulceration  is  usually  both  extensive  and  inapt  to 
heal.  Now,  though  the  relations  "^of  the  procident  womb  differ 
materially  from  those  of  the  organ  while  still  in  situ,  though  its 
sensil)ilitie8  are  unquestionably  much  blunted  by  its  change  of 
position,  yet  the  general  absence  of  any  abundant  discharge  either 
li-oni  the  cavity  of  tlie  w^omb,  or  from  the  canal  of  its  cervix,  as 
w^ell  as  of  the  other  symptoms  supposed  to  characterize  inflamma- 
tion of  the  neck  of  the  womb,  cannot  but  raise  a  presumption 
unfavorable  to  the  opinion  that  ulceration  of  the  os  uteri  is  the 
all-important  aft'ection  wliich  it  has  been  assumed  to  be  by  some 
writers. 

If,  however,  we  grant  that  between  the  procident  uterus  and 
the  organ  still  in  situ  there  are  differences  sufficient  to  prevent 
our  a[)plying  rigorously  to  the  one  conclusions  drawn  from  the 
other,  there  is  yet  another  source  wdience  evidence  may  be  de- 
duced to  show  that  the  os  and  cervix  uteri  are  less  susceptible  to 
disease,  and  that  disease  has  less  disposition  to  increase  and  to 
assume  a  serious  character  than  has  been  sometimes  imagined. 
There  is  no  class  of  persons  in  whom  to  such  a  degree  as  in  pros- 
titutes we  meet  with  the  conditions  best  calculated  to  inflict  local 
injury  on  the  neck  of  the  uterus.  It  would  therefore  be  reasona- 
ble to  expect,  if  the  susceptibility  of  the  cervix  uteri  have  not 
been  greatly  overrated,  that  in  these  women  we  should  discover 
with  remarkable  frequency  and  intensity  an  ulcerated  condition 
of  the  OS  uteri,  an  indurated  and  hypertrophied  state  of  its  cervix. 
Moreover,  as  an  hypertrophied  cervix  uteri  returns,  even  in  favor- 
able circumstances,  extremely  slowly  to  its  original  size,  there 
would  be  many  occasions  in  which  the  chronic  effects  of  bygone 
inflammation  must  be  evident  in  those  who  had  devoted  them- 
selves for  months  or  years  to  a  vicious  life. 

Observations,  however,  seem  to  show  that,  be  the  causes  of  ul- 
ceration of  the  OS  uteri,  of  inflammation,  hypertrophy,  and  indur- 
ation of  its  cervix  what  they  may,  sexual  excesses,  at  any  rate, 
have  no  great  share  in  their  production.  I  found  some  years  ago, 
on  investigating  this  subject,  that  in  twenty-seven  out  of  forty 
women  admitted  into  the  venereal  wards  of  the  hospital,  the  os 
and  cervix  uteri  were  quite  healthy.  In  ten  more  the  only  mor- 
bid condition  was  a  mere  excoriation  not  above  a  line  in  breadth, 
partially  or  completely  circumscribing  the  os  uteri,  but  associated 
with  no  other  change  of  its  tissue.  ^In  the  remaining  three  the 
ulceration  was  more  extensive,  but  in  one  only  of  these  (and  she 
a  woman  who  had  given  birth  to  children)  were  the  lips  of  the  os 
uteri  at  all  enlarged,  while  in  no  instance  was  there  any  such 


106  CONCLUSIONS    WITH    REFERENCE 

alteration  of  the  texture  of  the  part  as  to  deserve  the  name  of 
induration. 

The  conclusion  which  we  are  warranted  in  drawing  from  the 
inquiry,  as  far  as  we  have  hitherto  pursued  it,  would  seem  to  be, 
that  the  coiulition  of  so-called  ulceration  or  abrasion  of  the  os 
uteri  is  far  from  infrequent,  even  in  cases  where  no  uterine  symp- 
toms were  complained  of  during  life;  but  that  it  is  usually  un- 
associated  with  other  important  afiections  of  the  uterus  such  as 
may  be  supposed  to  be  the  effect  of  inflammatory  action :  and 
further,  that  such  affections  do  not  seem  to  be  readily  excited  by 
causes  acting  on  the  neck  of  the  womb,  either  when  displaced  or 
when  the  organ  is  in  its  natural  position. 

We  are  bound,  however,  to  go  a  step  further,  and  to  inquire 
whether,  in  the  case  of  persons  suffering  from  uterine  ailments, 
there  are  such  differences  either  in  kind,  degree,  or  duration  of 
the  symptoms,  according  as  ulceration  of  the  os  uteri  is  either 
absent  or  present,  as  would  enable  us  to  connect  with  it  certain 
definite  consequences,  or  to  say  that  it  tends  to  certain  definite 
results  such  as  do  not  otherwise  occur. 

Considering  that  in  the  opinion  of  some  writers,^  so  large  a 

•  Dr.  Henry  Bennct,  at  page  36  of  his  Treatise  on  Infammntion  of  the  Vtenis, 
&c.,  8vo.,  ;\d  edition,  London,  1858,  makes  this  statement.  In  accordance  with 
this  view,  too,  he  observes  at  page  6,  that  "  in  nearly  five  cases  out  of  six  of  uterine 
disease,  in  which  chronic  discharges,  mucous,  puriform,  or  sanguinolcnt,  or  other 
well-marked  uterine  symptoms,  are  present,  there  is  inflammatory  ulceration  of  the 
cervix."  His  theoretical  opinions,  however,  seem  to  be  undergoing  modifications 
more  considerable  than  he  himself  is  fullj-  aware  of.  In  his  Review  of  the  Present 
State  of  Uterine  Pathology,  which  appeared  in  the //(7nce<  during  the  spring  of  1856, 
and  which  was  afterwards  published  as  a  separate  work,  he  denies  having  "ever 
looked  upon  it  as  a  disease  per  se,  having  a  separate  existence — a  separate  patho- 
logical entity;"  apparently  forgetting  statements  such  as  those  which  1  have  quoted, 
and  also  the  no  less  significant  fact  that  226  out  of  the  359  pages  of  which  the  first 
part  of  his  book  is  composed  are  occupied  with  the  consideration  of  inflauimation 
and  ulceration  of  the  neck  of  the  womb;  only  37  with  the  study  of  inflammation, 
acute  or  chronic,  of  the  bodj'  of  the  organ.  In  this  Review,  too,  afiections  of  the 
body  of  the  uterus  are  recognized,  though  only  incidentally,  in  a  manner  suggestive 
of  a  f requeue}^  and  importance  much  more  considerable  than  would  be  inferred  by 
readers  of  his  larger  work,  while  he  altogether  abandons  the  doctrine  on  which  so 
much  stress  has  been  laid  of  the  special  importance  of  ulceration  of  the  os  uteri.  I 
inferred  it  to  be  usually  of  little  moment,  because,  whether  it  be  present  or  absent, 
"a  very  great  degree  of  resemblance  exists  between  the  two  classes  of  cases: 
women  of  the  same  age,  in  similar  circumstances,  presenting  the  same  symptoms, 
leading  to  the  same  results,  having  the  same  duration,  and  attended  with  similar 
structural  changes,  whether  ulceration  of  the  os  uteri  is  present  or  absent."  Dr. 
Bennet  concludes.  Review,  p.  31,  that  the  "  two  groups  of  patients  were  laboring 
in  a  great  measure  ifnder  the  same  disease,  only  manifesting  its  existence  in  one 
group  by  one  mode  of  expression,  in  the  other  group  by  another  mode  of  ex- 
pression." The  indiscriminate  use  of  caustics  will  probably  not  very  long  outlast 
the  recognition  of  the  fact  that  ulceration  of  the  os  uteri  is  but  one  mode  of 
expression  of  uterine  disease  ;  in  other  words,  an  accident — not  an  essential  char- 
acter. Dr.  Bennet,  indeed,  considers  this  conclusion  valueless;  to  my  mi/id  it  is 
one  of  great  practical  moment,  and  one  which  appears  to  me  to  be  already  bearing 
fruit. 

Having  had  occasion  thus  to  refer  to  Dr.  Bennet,  I  cannot  let  pass  the  opportu- 
nity of  avowing  my  sense  of  the  obligation  under  which  he  has  laid  the  profession 
in  this  country,  not  only  by  the  attention  which  he  has  drawn  to  the  subject  of 
uterine  disease  in  general,  but  also  by  many  of  his  own  observations,  and  especially 


TO    THESE    OPINIONS.  107 

proportion  as  81  per  cent,  of  all  women  presenting  symptoms  of 
uterine  ailment  are  suffering  from  inflammatory  disease  of  the 
tissue  or  canal  of  the  cervix  uteri,  and  70.4  per  cent,  likewise  from 
ulceration  of  the  os  uteri,  this  inquiry  can  scarcely  he  expected  to 
be  difficult  to  answer.'  The  evidence  in  support  of  the  importance 
as  well  as  of  the  frequency  of  these  affections  may  fairly  be  ex- 
pected to  be  overwhelming;  and  the  symptoms  of  ulceration  of 
the  OS  uteri  to  be  characteristic,  either  from  their  peculiarity  or 
their  severity,  or  from  both  together;  and  to  differ  in  important 
respects  from  such  as  attend  upon  those  uterine  ailments  which 
are  unassociated  with  that  condition. 

There  is  not  time  in  a  course  of  Lectures  on  the  Diseases  of 
Women  to  carry  you  step  by  step  through  the  whole  of  this  inquiry, 
which  some  years  since  I  made  the  theme  of  my  Croonian  Lec- 
tures. It  must  suffice  then  to  say,  that,  dividing  all  cases  in  which 
the  alleged  symptoms  of  uterine  ulceration  were  present  into  two 
classes,  according  as  examination  with  the  speculum  discovered 
that  condition  or  showed  it  to  be  absent,  I  endeavored  to  ascertain 
wliether  sterility  is  more  frequent,  whether  the  rate  of  fecundity 
is  lower,  and  whether  abortion  occurs  oftener  in  the  one  class  of 
cases  than  in  the  other?  Whether  menstrual  disorder  is  more 
common,  more  severe,  or  different  in  kind;  whether  leucorrhcBa 
is  more  abundant,  or  furnished  from  a  different  source ;  or  whether 
pain  is  less  tolerable  when  the  os  uteri  is  ulcerated  than  when  tliat 
condition  is  absent?  And  lastly,  whether  similar  or  different 
causes  produce  the  uterine  affection  in  the  two  classes  of  cases; 
whether  the  duration  of  illness  is  the  same  ;  whether  the  structural 
alterations  of  the  womb  are  alike  or  diverse  ? 

Each  of  these  questions  was  made  the  subject  of  special  inquiry, 
and  the  general  results,  from  which  more  extended  observation 
has  not  led  me  to  differ,  may  be  summed  up  as  follows : 

1st.  Uterine  pain,  menstrual  disorder,  and  leucorrhoeal  dis- 
charges— the  symptoms  ordinarily  attributable  to  ulceration  of  the 
OS  uteri — are  met  with  independently  of  that  condition  almost  as 
often  as  in  connection  with  it. 

2(1.  These  symptoms  are  observed  in  both  classes  of  cases  with 
a  vastly  preponderating  frequency  at  the  time  of  the  greatest  vigor 
of  the  sexual  functions,  and  no  cause  has  so  great  a  share  in  their 
production  as  the  different  incidents  connected  with  the  active 
exercise  of  the  reproductive  powers.  But  it  does  not  appear  that 
ulceration  of  the  os  uteri  exerts  any  special  influence  either  in 
causing  sterility  or  in  inducing  abortion. 

3d.  While  the  symptoms  are  identical  in  character  in  the  two 
classes  of  cases,  they  seem  to  present  a  slightly  increased  degree 

by  his  remarks  on  the  subjoct  of  uterine  displacements,  and  on  the  diagnosis  of 
uterine  cancer. 

1  Hcniiii;,  op.  cit.  p.  08,  found  the  proportion  to  be  17  per  cent.,  and  in  9  only 
of  tiic  17  did  the  morbid  condition  of  the  os  coexist  with  leucorrha-al  discharge 
from  the  cervix. 


108  LOCAL    TREATMENT 

of  intensity  in  those  cases  in  which  ulceration  of  the  os  uteri 
exists. 

4th.  In  as  far  as  could  be  ascertained  by  careful  examination, 
four-fifths  of  the  cases  of  either  class  presented  appreciable  changes 
in  the  condition  of  the  uterus — such  as  misplacement,  enlarge- 
ment, and  hardening  of  its  tissue,  while  frequently  several  of  these 
conditions  coexisted.  An  indurated  and  hypertrophied  state  of 
the  cervix  uteri  was,  however,  more  frequent  in  connection  with 
ulceration  of  the  os  uteri  than  independently  of  that  condition. 

5th.  The  inference,  however,  to  which  the  last-mentioned  fiict 
would  seem  to  lead,  as  to  the  existence  of  some  necessary  relation 
— such  as  that  of  cause  and  effect — between  ulceration  of  the  os 
uteri  and  induration  of  its  cervix,  is  in  great  measure  negatived 
by  two  circumstances. 

1.  That  in  numerous  instances  an  indurated  cervix  coexisted 
with  a  healthy  os  uteri. 

2.  That  while  in  many  of  the  cases  in  which  induration  of  the 
cervix  existed,  the  ulceration  of  the  os  was  very  slight,  induration 
was  entirely  absent  in  other  instances  where  the  ulceration  was 
noticed  as  having  been  very  extensive. 

Since,  then,  we  find  that  a  very  great  degree  of  resemblance 
exists  between  the  two  classes  of  cases;  that  women  of  the  same 
age,  in  similar  circumstances,  present  the  same  symptoms,  leading 
to  the  same  results,  having  the  same  duration,  and  attended  with 
similar  structural  changes,  whether  ulceration  of  the  os  uteri  is 
present  or  absent ;  it  may  fairly  be  inferred,  that  ulceration  of  the 
womb  is  neither  a  general  cause  of  uterine  disease,  nor  a  trust- 
worthy index  of  its  progress;  and  it  follows,  I  think,  as  a  necessary 
corollary  that  the  endeavor  by  local  remedies  to  remove  this  con- 
dition of  the  OS  is  not  the  all-important  ohject  in  the  treatment 
of  uterine  disease  which  the  teaching  and  the  practice  of  some 
physicians  Avould  lead  us  to  imagine. 

But  opinions,  such  as  these  which  I  have  expressed,  are  met  not 
infrequently  by  the  statement,  that  recover}^  from  various  uterine 
ailments  is  daily  seen  to  follow  the  employment  of  caustic  and  the 
application  of  various  local  remedies  exclusively  directed  against 
ulceration  of  the  os  uteri.  Now,  though  I  may  not  fully  acquiesce 
in  this  statement,  it  would  be  worse  than  idle  to  deny  that,  in 
many  instances,  the  application  of  caustic  to  the  os  uteri  has  been 
succeeded  by  the  restoration  of  the  patient  to  health.  The  fact, 
however,  admits  of  a  solution,  and  one  involving  a  principle  which 
finds  its  application  in  the  treatment  of  many  diseases  besides 
those  which  are  peculiar  to  the  female  sex. 

It  should  be  borne  in  mind  that  in  connection  with  this  mode 
of  treatment  various  other  measures  are  of  necessity  adopted 
eminently  calculated  to  relieve  many  of  the  slighter  forms  of 
uterine  ailments.  The  married  woman  is  for  a  time  taken  from 
her  husband's  bed ;  the  severe  exertion  to  which  eitlier  a  sense  of 
duty  urged  or  a  love  of  pleasure  prompted  her,  is  discontinued; 
while  rest  in  the  recumbent  posture  places  the  uterus  and  the 


SOMETIMES     MISCHIEVOUS.  109 

pelvic  viscera  in  just  that  position  in  which  the  return  of  blood 
from  them  encounters  the  smallest  difficulties.  The  condition  of 
the  bowels,  probably  before  habitually  neglected,  is  now  carefully 
regulated;  and  the  patient's  diet,  bland,  nutritious,  and  unstiinu- 
lating,  often  differs  widely  from  that  with  which,  while  all  her 
functions  were  overtaxed,  she  vainly  strove  to  tempt  her  fading 
appetite.  Add  to  this,  that  the  occurrence  of  the  menstrual  period 
is  carefully  watched  for;  that  all  precautions  are  then  redoubled, 
and  each  symptom  of  disorder,  such  as  on  former  occasions  had 
been  borne  uncomplainingly,  though  often  not  without  much  suf- 
fering, is  at  once  encountered  by  its  appropriate  remedy;  w'hile, 
generally,  returning  convalescence  is  met  in  the  higher  classes  of 
society  by  a  quiet  visit  to  the  country,  or  to  some  watering-place, 
in  pursuit  not  of  gayety  but  of  health ;  and  we  have  assembled  just 
those  conditions  best  fitted  to  remove  three  out  of  four  of  the  dis- 
orders to  w^hich  the  sexual  system  of  woman  is  subject.  But  the 
very  simplicity  of  these  measures  is  a  bar  to  their  adoption  ;  for 
it  is  a  matter  of  constant  observation,  that  the  rules  which  common 
sense  cannot  but  approve,  but  which  seem  to  require  nothing  more 
than  conmion  sense  to  suggest  tliem,  are  just  those  to  which  our 
patients  least  readily  submit.  The  case  is  altered,  however,  wdien 
the  same  rules  are  laid  down,  not  as  the  means  of  cure  themselves, 
but  only  as  conditions  indispensable  to  the  success  of  that  cauter- 
ization which,  repeated  once  or  oftener  in  the  week,  is  the  great 
remedy  for  the  ulceration  that  the  doctor  has  discovered,  and 
which  he  assures  his  patient,  and  with  the  most  perfect  good  faith, 
produces  all  the  symptoms  from  which  she  sufiers.  The  caustic 
used  in  these  milder  cases  is  the  nitrate  of  silver;  the  surface  to 
wdiich  it  is  applied  is  covered  by  a  thin  layer  of  albuminous  secre- 
tion not  easy  to  remove  completely,  and  which  serves  greatly  to 
diminish  the  powers  of  the  agent,  while  the  slightly  stimulating 
action  that  it  nevertheless  exerts  seldom  does  harm — sometimes,  I 
believe,  does  real  good,  though  no  more  than  might  have  been 
equally  attained  by  vaginal  injections,  or  by  other  similar  reme- 
dies, which  the  patient  might  have  employed  without  the  inter- 
vention of  her  medical  attendant. 

It  would,  however,  be  a  matter  of  comparatively  little  moment 
whether  the  views  which  I  believe  to  be  erroneous  were  so  or  not, 
if  their  reception  involved  nothing  more  than  an  over-estimate  of 
the  value  of  certain  therapeutical  proceedings  which  may  in  reality 
be  unessential  to  the  patient's  cure.  But  their  evil,  if  they  be 
erroneous,  is  of  a  far  graver  kind,  and  the  manner  in  which  they 
act  injuriously  on  the  patient  is  not  hard  to  understand.  No  one 
engaged  in  the  practice  of  medicine  but  must  have  been  often 
struck  with  the  important  part  which  the  sexual  system  plays, 
unconsciously  to  herself,  in  almost  all  the  diseases  of  women.  The 
frequent  sadness  and  low  spirits  in  celibacy,  the  grief,  the  almost 
shame,  of  childless  marriage,  depend  on  causes  more  dee|)ly  seated 
than  reason  can  dispel,  and  are  familiar  to  us  as  often  stamping  a 
peculiar  character  on  the  diseases  of  our  patients.     To  the  same 


110  USE    OF    CAUSTICS 

cause  is  clue  the  nervous  susceptibility  whicli  women  often  mani- 
fest on  the  least  symptom  of  ailment  affecting  their  uterine  system ; 
to  control  which,  and  to  prevent  the  disposition  to  unconscious  ex- 
aggeration of  their  symptoms,  becomes  often  one  of  our  most  im- 
portant, and  at  the  same  time  one  of  our  least  easy  duties.  Any 
course  of  proceeding,  then,  which,  without  the  most  urgent  and 
absolute  necessity,  directs  the  patient's  attention  in  the  slighter 
ailments  painfully  and  frequently  to  her  uterine  system,  is  in  the 
highest  degree  objectionable.  The  patient  recovers  from  her  ill- 
ness, but  with  the  impression  that  all  the  sensations  that  for  weeks, 
or  months  before,  she  had  experienced  were  exclusively  due  to  the 
local  disease  which  had  called  for  local  remedies.  On  the  first  re- 
turn of  any  symptoms  resembling  them,  all  her  apprehensions  are 
revived  lest  the  same  painful  investigation,  the  same  distressing 
manipulations  as  before,  should  be  again  required.  The  fact  that 
it  needs  but  to  watch  the  beatings  of  one's  heart  for  a  few  minutes, 
in  order  notably  to  quicken  its  pulsations,  and  to  become  painfully 
conscious  of  its  action,  is  one  of  the  most  familiar  illustrations  of 
that  influence  of  attention  upon  the  functions  of  the  body,  of  which, 
both  in  health  and  in  disease,  we  see  so  many  instances.  Diges- 
tion watched  through  its  difierent  stages  with  the  not  unnatural 
anxiety  of  a  dyspeptic  invalid,  often  leaves  him  a  hypochondriac, 
unable  to  take  other  than  certain  articles  of  diet,  and  those  cooked 
in  some  peculiar  fashion  ;  while  in  many  instances,  neither  in  the 
food  itself  nor  in  its  mode  of  preparation.is  there  any  reason  to  be 
found  why  that  alone  should  be  tolerated  by  his  fastidious  stomach. 
More  or  less  discomfort — often,  indeed,  nmch  positive  pain — at- 
tends in  the  great  majority  of  women  upon  the  performance  of  the 
menstrual  function,  precedes  or  follows  it.  These  pains  are  now 
thought  to  be  of  more  importance  than  before;  their  occurrence  is 
watched  for,  the  sufl'ering  of  one  month  is  weighed  against  that  of 
the  month  before,  as  the  woman  thinks  she  finds  in  its  increase  or 
its  diminution  grounds  for  hope  or  for  apprehension.  But  the  sen- 
sations thus  attended  to  increase  in  intensity  and  in  persistence  ; 
the  slight  ailment,  which  but  for  the  coming  evil  that  it  is  supposed 
to  portend,  would  in  a  few  days  be  forgotten,  is  noted  with  anxious 
vigilance  ;  and  the  more  it  is  observed,  the  more  it  seems  to  grow; 
the  patient  fears  she  never  will  be  well  again,  and  at  length  makes 
up  her  mind  once  more  to  go  through  the  same  treatment  as  be- 
fore relieved  her,  though  it  brought  to  her  the  painful  revelation 
of  the  grave  cause  on  which  her  suflfcrings,  once  thought  so  little 
of,  in  reality  depended.  Such  persons  among  the  poor  come  to 
our  hospitals,  and  on  questioning  them  as  to  their  ailments,  they 
at  once,  and  without  waiting  to  describe  their  symptoms,  say  that 
they  are  suflering  from  ulceration  of  the  womb ;  though  on  exami- 
nation one  finds  no  traces  of  it,  or  at  most  a  little  redness  of  the 
edges  of  the  os  uteri ;  or  it  may  be  even  that  slight  abrasion  which 
I  trust  that  I  have  shown  to  be  as  trivial  in  importance  as  it  is  fre- 
quent in  occurrence.  But  though  they  have  no  serious  disease, 
they  are  not  the  less,  or  perhaps  one  might  say  all  the  more,  real 


AND    ITS    EVILS.  Ill 

suiFerers,  and  sufferers  most  difficult  to  cure.  The  treatment  they 
perhaps  are  once  more  subjected  to  serves  but  to  confirm  the  mor- 
bid habit  of  mind  which  has  been  gradually  increasing  upon  them, 
and  destroying  both  their  present  happiness  and  their  capacity  for 
it  in  future  years. 

But  though  it  is  my  conviction  that,  in  the  great  majority  of 
instances  in  which  the  nitrate  of  silver  is  applied  to  the  os  uteri, 
the  proceeding  is  simply  superfluous,  it  yet  would  not  be  right  to 
leave  unnoticed  other  cases  in  which,  the  neck  of  the  womb  being 
more  or  less  enlarged,  stronger  agents  are  employed.  On  these 
occasions  the  caustic  potash  is  generally  used,  and  by  some  with 
the- view  of  destroying  outright  a  certain  portion  of  the  enlarged 
cervix;  by  others,  with  the  intention  of  getting  rid  of  the  enlarge- 
ment by  means  of  the  inflammation  which  it  sets  up  in  the  uterine 
tissue.  With  whichever  object  resorted  to,  the  proceeding  is  con- 
fessedly devoid  neither  of  suffering  nor  of  danger.  If  the  caustic 
be  introduced,  as  is  usually  done,  within  the  cervical  canal,  it  is 
allowed  that  the  pain  produced,  and  which  sometimes  lasts  for 
two  or  three  days,  is  very  intense,  causing  nausea  or  sickness,  and 
sometimes  even  syncope,  or  occasioning  extreme  depression,  pros- 
trating a  patient  so  completely  as  to  render  her  unable  to  quit  her 
bed  or  sofa  for  several  days.  Thus  much  for  the  present  eflect  of 
this  remedy,  for  which  its  strongest  advocates  can  scarcely  lay  claim 
to  such  an  ei)ithet  as  jucunde.  But  it  does  not  fare  better  with  it 
as  far  as  cito  is  concerned.  The  application  of  the  potassa  fusa  so 
as  to  produce  an  eschar,  implies  a  subsequent  course  of  treatment 
with  frequent  applications  of  the  nitrate  of  silver  for  a  period  of 
about  forty  days,  at  the  end  of  which  time,  the  action  of  the 
remedy  being  supposed  to  be  exhausted,  unless  the  patient  is  cured, 
it  will  be  necessary  to  repeat  the  same  treatment  again  and  again. 
This  treatment,  too,  it  will  be  observed,  confines  the  patient  dur- 
ing the  whole  time  that  it  is  in  progress  to  her  room,  and  almost 
to  her  couch,  and  entails  upon  her  the  necessity  of  one  or  two  ex- 
aminations with  the  speculum  every  w^eek  during  its  continuance. 
But  if  it  can  be  said  to  act  neither  cito  nor  jucunde,  it  might  be 
hoped  that  this  mode  of  proceeding  had  at  least  the  third  merit  of 
tuto  ;  but  it  has  not.  The  tendency  to  contraction  or  obliteration 
of  the  cervical  canal  after  these  proceedings  is  very  considerable, 
and  is  referred  to  as  even  a  frequent  occurrence  ;  while  inflamma- 
tion both  of  the  uterus  generally,  and  of  its  appendages,  is  a  con- 
tingency far  from  uncommon.  Of  the  last  of  these  accidents  I 
have  seen  several  instances  among  patients  at  the  hospital,  who, 
previous  to  their  coming  under  my  care,  had  been  treated  with 
the  stronger  caustics  for  ulceration  of  the  os  uteri. 

I  will  not  attempt  to  follow  the  advocates  of  this  practice  through 
the  explanation  which  they  give  of  its  mode  of  action ;  and  tlie 
rather,  since  where  some  see  a  healthy  stimulus  to  the  affected 
tissues,  others  discern  what  they  consider  to  be  a  dulling,  stupe- 
fying influence,  as  they  term  it,  weakening  the  vital  foire;  while 
throughout  the  language  used  with  reference  to  this  subject  there 


112  EVILS    OF    USE    OF    CAUSTICS. 

is  a  mingling  of  metaphor  with  scientific  termhiology,  from  which 
it  is  extremely  difficult  to  arrive  at  a  clear  notion  of  what  is  meant. 
I  do  not  doubt  but  that  by  either  mode  of  applying  the  caustic 
potass,  the  cervix  uteri  may  be  reduced  in  size;  but  my  dissent 
from  the  practice  is  founded  on  the  fact  that  it  has  none  of  the 
three  recommendations  of  painlessless,  speed,  or  safety;  while  my 
own  experience  would  lead  me  to  believe  that  when  adopted  it  is 
usually  either  out  of  place  or  superfluous.  During  the  presence 
of  any  active  symptoms  of  inflammation,  such  a  proceeding  as  the 
destruction  of  a  portion  of  the  uterine  tissue  by  caustics  cannot 
but  be  perilous;  after  their  removal  the  womb  will  return  slowly, 
often  indeed  but  imperfectly,  to  its  previous  size.  This  return, 
however,  does  take  place,  as  far  at  least  as  my  experience  goes,  in 
the  immense  majority  of  cases,  and  takes  place  as  surely,  and  not 
much,  if  at  all,  more  slowly,  under  just  those  conditions  which 
best  promote  the  general  health,  as  under  a  course  of  treatment 
which,  apart  from  other  evils,  confines  a  woman  for  weeks  and 
months  to  her  chamber  and  her  couch,  to  the  grievous  impairment 
of  her  general  health,  and  the  utter  ruin  of  her  cheerfulness,  as 
on  several  occasions  I  have  had  the  opportunity  of  observing. 
Moreover,  very  wide  variations  in  the  size  of  the  womb  seem  to 
be  equally  compatible  with  the  healthy  performance  of  its  func- 
tions, while  the  special  tendency  which  it  exhibits  in  any  circum- 
stances that  produce  congestion  of  its  vessels  to  increase  in  size 
must  never  be  forgotten  in  estimating  the  pathological  importance 
of  hypertrophy,  either  of  the  whole  or  a  part  of  the  organ.  In 
this  opinion,  too,  I  am  further  strengthened  by  the  fact  that  some 
of  the  most  marked  instances  of  enlargement  of  the  neck  of  the 
womb,  with  increased  hardness  of  its  tissues,  which  have  come 
under  my  observation,  occurred  in  cases  where  there  was  no  trace 
of  ulceration  either  of  the  os  uteri  or  of  the  canal  of  its  cervix. 

But  I  must  stop  here,  and  reserve  for  the  next  lecture  the  en- 
deavor to  show  what  opinions  seem  to  me  better  substantiated, 
and  what  practice  more  judicious,  than  those  which  I  have  hitherto 
been  engaged  in  criticizing. 


LECTURE    VIII. 

INFLAMMATORY  AFFECTIONS  OF  THE  IJTEEUS. 

Chkonic  Inflammation  and  its  Eesxjlts,  continued.  Evidence  of  general  de- 
pendence of  symptoms  on  affection  of  body  of  uterus,  and  independence  of 
ulceration  of  os — illustrative  cases.     Objections  answered. 

Hypothesis  of  primary  affection  of  cervical  canal  considered ;  and  reasons  assigned 
for  dissenting  from  it. 

Treatment  of  these  cases;  depletion,  sedatives,  use  of  mercurials,  use  and  selection 
of  tonics.  Vaginal  injections.  Exceptional  cases  requiring  local  treatment 
of  ulceration. 

Cases  of  cervical  leucorrhcea  ;  their  nature  and  treatment. 

The  last  Lecture  was  occupied  almost  entirely  with  the  endeavor 
to  point  out  the  fallacy  of  a  certain  hypothesis  which  professed  to 


AFFECTIONS  OF  THE  UTERUS.  113 

explain  the  occurrence  of  menstrual  irregularities,  leucorrhoeal  dis- 
charges, and  uterine  pain,  by  referring  them  to  a  single  cause,  and 
regarding  them  as  the  invariable,  or  almost  invariable,  conse- 
quences of  inflammation  of  the  cervix  and  ulceration  of  the  os 
uteri. 

It  remains  for  us  now,  however,  to  inquire  to  what  other  cause 
or  causes  these  symptoms  may  be  attributed,  and  to  ascertain,  if 
possible,  in  what  circumstances  the  local  affection  of  the  os  uteri 
is  to'be  regarded  as  occasioning  special  aggravation  of  the  patient's 
symptoms,  and  as  calling  for  special  local  treatment. 

In  the  course  of  former  lectures  many  remarks  have  been  already 
anticipated,  which  might  otherwise  find  here  a  most  appropriate 
place.  It  can,  indeed,  scarcely  be  necessary  to  repeat  what  I  have 
already  said  with  reference  to  the  connection  of  menstrual  irregu- 
larity and  leucorrhoeal  discharges  with  hepatic  disorder,  or  Avith 
the  gouty  or  rheumatic  diathesis.  Such  conditions  are  of  them- 
selves amply  sufficient  to  account  for  symptoms  which  the  patient 
may  refer  to  the  womb ;  and  so  long  as  they  are  unremoved,  it  is 
idle,  or  worse  than  idle,  to  attempt  a  cure  by  local  treatment. 

But  there  is,  besides,  a  large  category  of  cases  in  which  the 
symptoms  date  back  to  pregnancy,  delivery,  or  miscarriage,  and  in 
which  the  enlargement  of  the  uterus,  as  well  as  the  history  of  the 
patient,  point  to  a  purely  local  cause  of  the  ailment.  In  these 
cases,  however,  it  is  the  body  of  the  womb  which  is  the  part  most 
affected,  since  as  it  bears  the  greatest  part  in  all  the  changes  that 
pregnancy  brings  with  it,  so  any  defect  in  the  involution  of  the 
organ  will  leave  its  body  more  enlarged,  the  lining  of  its  cavity 
more  vascular,  than  are  the  walls  or  the  lining  of  the  cervical  canal. 
Often,  indeed,  but  by  no  means  always,  enlargement  of  the  neck 
of  the  womb  accompanies  enlargement  of  its  body,  but  the  former 
is- not  the  occasion  of  the  latter, — is,  I  believe,  secondary  in  the 
order  of  time,  and  subordinate  in  point  of  importance.^ 

In  40  per  cent,  of  all  the  cases  that  came  under  my  observa- 
tion, the  patient's  history  went  back  to  one  or  other  of  these  last- 
named  exciting  causes ;  for,  indeed,  it  is  not  possiljle  to  conceive 
of  a  state  of  things  more  favorable  than  they  to  the  supervention 

1  "While  those  shoots  •were  passing  through  tlie  press,  Scanzoni's  elaborate 
treatise  on  chronic  intlammation  of  the  womb  [Die  ch7-onische Me(ri/is,Svo.,  "W'icn, 
18G3),  came  into  my  hands,  thoiigii  too  late  for  me  to  make  that  u<e  of  it  which 
1  should  have  otherwise  wished  to  do.  I  may,  however,  be  excused  for  expressing 
my  satisfaction  at  finding  the  opinions  which,  more  than  ten  years  since,  1  jiut 
forth  in  my  Croonian  Lectures,  so  fully  boi'ue  out  by  the  large  experience  of  the 
German  professor.  ' 

"Any  un])rejudiced  observer,"  says  he,  "must  come  to  the  conclusion  that  the 
importance  of  the  so-called  inllam;natory  atl'eclions  of  the  neck  of  the  womb  has 
been  too  much  over-estimated  in  the  course  of  the  last  twenty  years;  that  many  a 
discomfort,  many  a  symptom  of  disease,  has  been  attributed  to  these  conditions, 
without  the  slightest  proof  of  any  real  connection  subsisting  between  them."' 

"  We,  for  our  jiart,  are  firmly  convinced  that  the  pathulogical  changes  of  the 
upper  portion  of  the  uterus  arc  of  much  greater  moment,  both  locally  as  well  as 
with  reference  to  the  disorder  which  thi-y  produce  in  distant  organs,  than  the 
recently  so  highly  estimated  swellings,  hypertrojihics,  granulations,  and  ulcerations 
of  the  cervix,"  p.  53. 


114  CHRONIC  .INFLAMMATION 

of  inflammation  and  of  kindred  processes.  And  if  it  does  come 
on,  we  find  its  attack  announced  by  pain  of  a  severer  kind,  and  of 
a  more  distinctly  paroxysmal  character  than  was  before  expe- 
rienced, sometimes,  indeed,  excruciating  in  severity;  while  even 
in  its  absence  there  is  extreme  tenderness  of  the  uterus,  with  great 
heat  of  the  vagina,  and  usually  a  very  abundant  purulent  leucor- 
rhoea ;  often,  though  by  no  means  invariably  tinged  with  blood. 
Moreover,  these  local  symptoms  are  associated  with  more  or  less 
considerable  constitutional  disturbance,  while  on  their  subsidence 
the  uterine  tissue,  as  far  as  its  state  can  be  ascertained,  is  felt  to 
be  harder  in  texture  than  before  ;  and  lastly,  these  symptoms,  when 
once  they  have  occurred,  are  apt  to  return  at  uncertain  intervals 
during  a  period  of  many  years,  presenting  on  each  occasion  the 
same  character,  amenable  to  the  same  treatment,  but  in  spite  of 
it  retaining  the  same  disposition  to  recur  over  and  over  again. 

In  September,  1851,  a  married  woman,  aged  forty-one,  was 
admitted  into  St.  Bartholomew's  Hospital,  and  told  the  following 
history  of  her  ailments:  Having  married  at  sixteen,  at  which 
time  the  menstrual  discharge  was  scanty,  and  irregular  in  its  return, 
she  at  once  became  pregnant,  but  miscarried  at  the  third  month. 
A  second  pregnancy  terminated  at  the  full  period,  after  a  linger- 
ing labor  of  two  days  and  a  half  duration,  in  the  eighteenth  year 
of  her  age ;  and  a  third  jiregnancy  soon  afterAA'ards  likewise  ter- 
minated prematurely  at  the  fourth  month.  Her  symptoms  dated 
from  the  time  of  her  lingering  labor,  and  consisted  of  leucorrhoeal 
discharge,  sometimes  very  copious,  occasionally  also  very  offen- 
sive; constant  sense  of  discomfort  in  the  uterine  region,  with 
occasional  sharp  stabbing  pains,  chiefly  referred  to  the  right  groin, 
and  always  aggravated  at  a  menstrual  [)eriod  ;  while  the  menstrual 
discharge,  which  for  years  had  been  gradually  increasing  in  quan- 
tity, and  was  now  extremely  profuse,  was  always  succeeded  by 
temporary  relief  to  the  patient's  sufliirings.  The  pain  and  the 
hemorrhage  together  liad  worn  down  her  health  ;  her  countenance 
was  anxious,  and  her  pulse  128,  and  feeble.  The  uterus  was  found 
to  be  rather  low  down,  but  not  much  enlarged,  though  very  tender; 
the  cervix  uteri  was  indurated,  somewhat  elongated,  and  very 
painful ;  and  the  os  uteri,  which  was  small  and  circular,  presented 
no  trace  of  abrasion,  either  ail'ecting  its  lips,  or  extending  into  the 
canal  of  the  cervix,  though  the  congestion  of  that  part  was  very 
marked.  Kest,  frequent  local  leeching,  and  sedatives,  relieved  the 
patient's  suflerings,  improved  diet  restored  her  strength,  and  Avhen 
she  left  the  hospital  in  jS^ovember,  she  had  lost  the  sense  of  pain 
and  bearing  down  ;  there  was  but  little  leucorrhcea,  the  tenderness 
of  the  uterus  was  much  diminished,  and  the  congestion  of  its 
orifice  had  entirely  disappeared.  It  may  be  added  that  once  during 
the  course  of  her  treatment,  superficial  abrasion  of  the  os  uteri 
showed  itself,  but  disappeared  of  its  own  accord  in  a  few  days. 
Great  as  the  relief  was  which  this  poor  woman  had  obtained,  I  did 
not  anticipate  that  she  would  continue  free  from  suflering  if  she 


OF    INTERIOR    OF    UTERUS.  Il5 

returned  home  to  bear  a  part  in  the  duties  and  to  submit  to  the 
hardships  which  are  inseparable  from  poverty. 

Accordingly,  in  less  than  twelve  months  she  returned  to  the 
hospital,  presenting  the  same  symptoms  as  before,  and  submitted 
to  a  similar  plan  of  treatment  with  the  like  result.  The  os  uteri 
on  this  occasion  also  presented  no  abrasion,  though  frequent  exam- 
inations were  made  with  the  speculum  to  ascertain  this  fact.  The 
patient  remained  this  time  somewhat  longer  than  before  in  the 
hospital,  and  took  small  doses  of  the  bichloride  of  mercury  for 
several  weeks,  though  never  in  such  quantities  as  to  atiect  the 
mouth.  For  six  months  after  her  discharge,  she  continued  almost 
free  from  suffering;  but  in  September,  1853,  her  symptoms  began 
to  return:  menstruation,  though  not  so  profuse  as  before,  became 
once  more  very  painful ;  and  for  some  clays  before  her  admission 
into  the  hospital,  on  October  20,  she  had  paroxysms  of  such  intense 
severity  that  she  rolled  about  the  bed  in  uncontrollable  agony, 
which  large  doses  of  sedatives  were  unable  to  subdue.  On  her 
admission  there  was  the  same  intense  congestion  of  the  os  uteri  as 
on  former  occasions,  with  a  very  abundant,  highly  offensive,  puru- 
lent discharge,  slightly  tinged  with  blood  from  its  interior;  the 
womb  itself  being  low  down,  somewhat  larger  than  natural,  and 
the  cervix  large,  hard,  swollen,  and  intensely  tender;  but  no  trace 
of  abrasion  of  the  os  was  perceptible.  The  application  of  six 
leeches  to  the  uterus  was  followed  by  bleeding  so  profuse  as  to  cause 
syncope  ;  but  for  several  days  subsequently  the  patient  continued 
perfectly  free  from  pain,  and  though  it  afterwards  returned,  yet  it 
never  again  attained  the  same  degree  of  intensity.  She  remained 
in  the  hospital  for  six  weeks,  during  which  time  local  leeching 
was  occasionally  resorted  to ;  small  doses  of  the  bichloride  of  mer- 
cury were  again  given,  together  with  the  syrup  of  the  iodide  of 
iron  ;  and  under  this  treatment  improvement  once  more  took  place, 
and  the  neck  of  the  womb,  at  the  time  of  the  patient's  discharge, 
was  at  least  a  third  smaller  than  it  had  been  at  her  admission. 

This  case  I  have  related,  both  for  the  illustratiou  it  affords  of 
the  treatment  by  which  these  symptoms  should  be  encountered, 
as  well  as  because  it  displays  the  symptoms  in  their  severest  form, 
and  recurring  with  tliat  pertinacity  which  is  one  of  the  most  painful 
characteristics  of  this  class  of  ailments.  I  apprehend  that  one  does 
not  err  in  connecting  the  commencement  of  this  patient's  illness 
with  some  inflammatory  affection  of  the  mucous  membrane  of  her 
uterus,  which  supervened  upon  her  delivery,  and  which,  during 
the  numy  subsequent  years,  was  every  now  and  then  lighted  up 
afresh  by  causes  such  as  in  the  household  of  the  poor  are  not  far 
to  seek.  It  would  not  be  dillicult  to  multiply  cases  of  this  dcsorip- 
tion  ;  but  in  further  exempliiication  of  the  subject,  1  will  just 
refer  to  one  other  of  a  kindred  nature.  In  some  few,  liapi)iiy 
very  few  cases,  the  inflanmiation,  which  in  gonorrhcea  is  usually 
limited  to  the  vagina,  not  only  attacks  the  mucous  membrane  of 
the  bladder,  but  affects  the  lining  of  the  uterus  also,  and  even 
extends  to  the  peritoneum,  sometimes  endangering  the  patient's 


116  INFLAMMATION    OF    BODY    OF    rTERUS. 

life.  But  without  causing  tliese  most  formidable  results,  acute 
inflammation  of  the  vagina  sometimes  extends  beyond  its  original 
seat,  and  gives  rise  to  symptoms  such  as  we  are  now  considering. 
A  patient,  aged  thirty-five,  was  admitted  into  St.  Bartholomew's 
Hospital,  complaining  of  dysuria  and  frequent  micturition,  ot 
painful  and  profuse  menstruation,  and  of  leucorrhoeal  discharge, — 
symptoms  which  she  referred  to  a  somewhat  severe  attack  of  gon- 
orrhoea three  months  before.  Iler  uterus  was  found  much  enlarged, 
anteverted,  and  fixed  in  its  unnatural  position,  while  its  tissue 
generally  was  much  harder  than  natural,  and  the  margins  of  the 
OS  uteri,  though  free  from  the  slightest  trace  of  abrasion,  presented 
very  marked  congestion,  and  discharge  was  poured  out  from  the 
interior  abundantly.  It  is  here,  I  think,  no  unfair  assumption  to 
suppose  that  all  these  symptoms,  from  which  the  patient  had  never 
suffered  previous  to  the  gonorrhoea,  were  excited  by  it, — and  that 
had  affected  the  interior  of  the  uterus,  and  had  also  bound  down 
the  organ  in  its  unnatural  position  by  adhesions  consequent  on 
peritoneal  inflammation. 

It  is  well  to  bear  in  mind,  with  reference  to  cases  of  this  and  of 
a  similar  kind,  that  the  assumption  of  inflammation  aftccting  the 
body  of  the  womb  is  not  sufficiently  negatived  by  the  absence,  in 
the  patient's  history,  of  any  mention  of  sj'mptoms  so  grave  as  we 
might  be  inclined  to  imagine  that  inflammation  of  the  more  im- 
portant parts  of  this  viscus  must  of  necessity  produce.  In  making 
examinations  after  death,  we  constantly  find  adhesions  between  the 
uterus  and  the  rectum,  or  matting  together  of  the  parts  within  the 
fold  of  one  or  other  broad  ligament,  although  the  patient  during 
her  lifetime  may  never  have  mentioned  any  attack  of  uterine  or 
abdominal  inflammation.  Not  infrequently,  too,  we  find  the  uterus 
firmly  fixed  in  the  pelvis,  with  most  obvious  thickening  of  the 
broad  ligament,  or  of  the  pelvic  cellular  tissue ;  while  yet  the 
closest  inquiry  will  fail  to  elicit  anything  more  definite  than  the 
statement,  that  a  bad  confinement  or  a  bad  miscarriage  some  time 
before  was  succeeded  by  a  painful  and  tedious  convalescence. 

Other  cases  might  be  mentioned  which,  I  believe,  admit  of  the 
same  interpretation, — cases  where  the  symptoms  have  succeeded 
to  marriage,  or  where  they  have  followed  suppressed  menstruation ; 
nor  would  I  propose  a  dificrent  explanation  of  those  instances  in 
which  uterine  misplacements,  as  anteflexion  or  retroflexion,  are 
succeeded  by  signs  of  sexual  disorder  such  as  we  have  been  con- 
sidering, or  where  they  have  been  associated  with  misplacement  of 
the  ovary.  In  all  of  these  cases  it  is,  I  believe,  the  interior  of  the 
uterine  cavity  which  suft'ers  first;  it  is  thence  that  the  hemorrhages 
are  derived,  thence  that  the  greater  part  of  the  leucorrhceal  dis- 
charge is  furnished;  and  it  is  the  irritation  of  that  part  of  the 
organ  in  which  its  most  important  functions  are  transacted,  that 
leads  to  the  increase  of  its  size  so  apparent  in  the  great  proportion 
of  cases  of  long-continued  uterine  ailment.  That  the  ovaries  sufier 
too,  constant  observation  proves ;  and  facts  illustrative  of  the  af- 
fection of  the  neck  of  the  womb  are  also  perpetually  coming  under 


AFFECTION  OF  CANAL  OF  CERVIX  UTERI..      117 

our  notice ;  but  there  does  not  seem  to  me  to  be  any  proof  that, 
as  a  general  rule,  the  point  of  departure  of  the  mischief  is  in  the 
neck  of  the  womb  any  more  than  at  its  orifice,  or  in  its  append- 
ages. 

There  are,  indeed,  some  writers,  who,  while  they  concede  the 
comparatively  small  importance  of  ulceration  of  the  os  uteri,  yet 
appear  to  me  scarcely, to  attach  due  weight  to  the  ailments  of  the 
uterine  cavity.  The  elaborate  secretory  apparatus  of  the  cervix 
uteri,  so  minutely  described  and  so  beautifully  delineated  by  Dr. 
Tyler  Smith  and  Dr.  Ilassall,'  seems,  indeed,  to  furnish  an  ample 
source  for  almost  any  conceivable  amount  of  discharge.  But  it 
must  be  remembered,  that  like  many  other  secreting  apparatuses, 
this  is  by  no  means  in  constant  activity.  Its  full  action  seems  to 
be  called  forth  only  during  pregnancy,  and  my  own  observation 
does  not  by  any  means  confirm  the  statement,  that  in  the  inter- 
vals between  the  menstrual  periods  a  mucous  plug  is  secreted, 
hermetically  closing,  as  it  were,  the  canal  of  the  cervix,  for  I  have 
observed  any  such  secretion  to  be  as  often  absent  as  present  in 
uteri  which  I  have  examined.  I  may  further  add,  that  Dr.  Ilen- 
nig,^  who  has  devoted  so  much  labor  to  the  subject  which  we  are 
now  considering,  expressly  states  pregnancy  to  be  the  only  physio- 
logical condition  in  which  this  mucous  plug  is  formed. 

These  alleged  facts  concerning  the  functions  of  the  cervical 
glands  have,  however,  been  made  the  groundwork  of  a  theory 
according  to  which  a  sort  of  antithetical  action  exists  between  the 
cavity  and  the  neck  of  the  womb ;  the  former  periodically  pour- 
ing out  the  menstrual  discharge,  the  latter  periodically  forming  a 
secretion  by  which  its  canal  is  closed,  until  with  each  menstrua- 
tion the  plug  is  removed.  Hypothetical  uses,  too,  connected  with 
the  generative  process,  are  assigned  to  this  secretion,  against  the 
validity  of  which  its  frequent  absence  is  one  of  the  most  cogent 
arguments.  In  'conformity,  too,  with  this  assumption  of  the 
physiological  condition  of  these  parts,  it  is  alleged  that  leucor- 
rhoea  is  in  general  merely  a  hypersecretion  from  the  glandular 
apparatus  of  the  cervix  uteri,  and  most  of  the  ills  which  in  this 
and  the  preceding  lecture  have  engaged  our  notice,  are  regarded 
as  merely  the  secondary  results  either  of  the  local  irritation  pro- 
duced by  the  discharge  on  adjacent  parts,  or  else  of  constitutional 
disorder  excited  by  purulent  absor))tion  owing  to  the  constant 
presence  of  the  morbid  secretion  in  the  vagina. 

There  is  something  so  attractive  in  ingenious  speculations,  that 
we  cannot  be  surprised  if  sometimes  they  are  propounded  a  little 

1  In  vol.  XXXV,  of  the  ]\Iedico-C/iir>ir(jicnl  Trnnsnctiomt ;  ami  aftorwanls  l>y  Dr. 
Tylor  Smith,  in  his  work  on  Lemorrltica,  8vo.,' London,  1855.  ]\[.  Iliignicr  was,  to 
th(^  best  of  my  boliof,  the  person  who  in  his  Lectures  at  the  llo/ufal  tic  I'Ourcine, 
published  in  the  Gazette  den  Ilupitaux,  for  1847,  clearly  enunciated  the  opinion 
that  the  main  source  of  leucorrhcea  was  to  be  .sought  in  aftVction  of  the  glandular 
apjiuratus  of  the  cervix  uteri,  and  sujiported  this  view  by  very  cogent  argument, 
though,  for  tlie  reasons  assigned  in  the  text,  1  have  ventured  to  dissent  from  the 
conclusion  at  which  both  he  and  other  subsequent  writers  hiive  arrived. 

2  Op.  cit,  p.  18. 


118  .  HYPOTHESIS    OF    EXCLUSIVE    AFFECTION 

hastily ;  and  this  is  all  the  more  likely  to  he  the  case  if  the  point  on 
which  they  rest  is  one  which  it  is  almost  impossible  to  determine 
with  certainty  by  actual  observation.  I  do  not  for  a  moment  doubt 
the  frequent,  perhaps  even  the  constant  admixture  of  secretion 
from  the  glands  of  the  cervix  with  that  from  the  cavity  of  the 
womb  in  ordinary  leucorrhoea ;  I  believe  that  in  some  cases  which 
will  be  hereafter  noticed,  such  secretion  makes  up  by  far  the 
greater  amount  of  the  discharge.  There  are  some  considerations, 
however,  which,  in  the  absence  of  any  means  of  positively  deter- 
mining during  the  lifetime  of  our  patients  whether  a  discharge 
poured  out  from  the  os  uteri  is  furnished  from  the  cervical  canal, 
or  from  liigher  up  in  the  hody  of  the  uterus,  or  from  both,  should 
make  us  hesitate  to  assign  so  little  importance  to  aiFections  of  the 
uterine  cavity  in  the  production  of  leucorrhoea  and  kindred  dis- 
ordei^.  Some  of  the  most  cogent  of  these  have  been  already  so 
fully  detailed,  that  it  seems  almost  superfluous  to  refer  once  again 
to  the  changes  tbat  succeed  delivery,  in  wbich  the  mucous  mem- 
brane of  the  cavity  of  the  womb  bears  so  much  greater  a  part  than 
that  of  the  cervix,  and  continues  to  pour  out  a  muco-purulent 
secretion  long  after  all  sanguineous  flow  has  ceased.  The  history 
of  an  ordinary  menstrual  period  affords  another  illustration  of  the 
same  fact.  The  mixture  of  mucus  and  epitlielium,  which  at  its 
commencement  and  end  constitutes  the  greater  part  of  the  men- 
strual flux,  is  not  only  assumed  to  be  furnished  from  the  congested 
mucous  membrane  of  the  body  of  the  uterus,  but  on  examination 
after  death  may  be  seen  not  only  in  its  cavity,  but  even  distending 
the  whole  length  of  the  Fallopian  tubes. ^  Whence,  too,  but  from 
such  a  source  could  it  flow,  as  it  sometimes  does  in  the  healthy 
subject  for  twelve  or  twenty-four  hours  after  the  cessation  of  all 
admixture  of  blood,  since  the  secretion  formed  in  tlie  cervical  canal 
must  be  removed  at  the  commencement  of  each  menstruation,  and 
the  periodical  functions  of  the  two  parts  of  the  womb  are  assumed 
to  be  performed  at  dift'erent  times?  Nor  must  it  be  forgotten,  that 
the  mucous  membrane  of  the  uterine  cavity  is  provided  with  appro- 
priate glands,  to  furnish  such  secretion,  almost  infinite  in  number, 
curiously  convoluted  to  increase  the  extent  of  their  surface,  and 
susceptible  of  a  peculiar  hypertrophy  more  remarkable  than  any 
which  is  observed  to  take  place  in  the  glands  of  the  cervix.  Ob- 
servation also  not  infrequently  discovers  the  membrane  of  the 
uterine  cavity  abundantly  moistened  with  secretion,  while  now 
and  then  accident  and  disease  bear  testimony  to  the  same  fact,  as 
in  the  case  of  the  inverted  uterus,  of  which  one  of  the  most  con- 
stant symptoms,  next  to  the  profuse  hemorrhage,  is  the  abundant 
leucorrhoea ;  or  of  the  inflamed  lining  membrane  of  the  womb 
when  some  accident  preventing  the  escape  of  the  secretion,  the 

1  It  seems  indeed  doubtful  whether  affection  of  the  Fallopian  tubes  does  not  play 
a  far  more  imywrtant  part  than  we  have  been  accustomed  to  suppose,  in  the  pro- 
duction of  many  of  the  ailments  of  the  female  sexual  sj'stem.  See  Hennig's  re- 
marks on  the  preponderance  of  .catarrh  of  the  tubes,  over  similar  affections  of  the 
body  or  neck  of  the  womb,  or  of  the  vagina. — 0/».  cit.,  p.  28. 


OF    CERVIX    UNTENABLE.  119 

cavity  of  the  organ  has  been  found  distended  by  an  accumulation 
of  pus.' 

Rejecting,  then,  the  supposition  that  the  symptoms  we  have  been 
considering  are  in  general  due  either  to  ulceration  of  the  os  uteri, 
or  to  some  affection  of  the  glands  of  its  cervix,  we  come  now  to 
inquire  into  their  most  appropriate  treatment.  This,  as  you  will 
readily  understand,  differs  widely,  according  as  the  symptoms  have 
anything  of  an  active  character,  or,  on  the  other  hand,  are  purely 
chronic,  though  in  both  cases  the  indications  to  be  met  are  but  few, 
and  the  means  to  be  employed  abundantly  simple.  So  long  as 
acute  symptoms  are  present,  or  whenever  they  reappear  in  the 
chronic  stage  of  the  disorder,  local  leeching  generally  affords  more 
speedy  and  more  decided  relief  than  any  other  remedial  means. 
The  leeches  should  be  applied  to  the  uterus  itself;  not  above  four 
in  number  at  a  time  ;  nor  is  it  in  general  expedient  to  repeat  their 
application  above  once  in  a  week  or  ten  days.  Another  precau- 
tion to  which  your  attention  has  already  been  called,  consists  in 
never  leeching  the  womb  w^ithin  four  or  five  days  of  a  menstrual 
period,  lest  the  regularity  of  that  function  be  disturbed,  either  by 
being  brought  on  prematurely,  or  (which,  however,  is  much  less 
frequent)  by  its  occurrence  being  postponed  for  several  days.  The 
pain  which  is  left  behind  after  menstruation  in  some  of  these  cases 
— in  those  especially  in  which  the  discharge  is  scanty — is  often 
very  greatly  relieved  by  the  ap})lication  of  a  few  leeches  as  the 
period  passes  oft'.  Next  to  the  abstraction  of  blood,  the  mitigation 
of  suftering  by  direct  sedatives  claims  our  attention.  After  what 
has  been  said  in  former  Lectures  on  this  subject,  I  will  now  merely 
remind  you  that  when  sedatives  may  be  long  needed,  the  milder 
the  preparation,  and  the  smaller  the  dose,  the  less  will  be  the  risk 
of  injury  to  the  health  from  their  continuance.  The  backache  is 
often  relieved  by  counter-irritation  to  the  sacrum,  which  is  usually 
more  efhcient  than  plasters  of  opium,  or  belladonna  ;  while  its 
good  eftects,  also,  are  in  general  less  transitory.  As  suitable  a 
preparation  for  this  purpose  as  any  is  a  croton-oil  liniment,  com- 
posed of  one  part  of  croton  oil  to  ten  of  the  simple  camphor-lini- 
ment, which  should  not  be  rubbed  into  the  sacrum,  but  merely 
applied  with  a  sponge  twice  a  day ;  and  while  thus  employed  will 
somewhat  irritate  the  skin,  but  without  producing  any  trouble- 
some pustular  eruption. 

'  Thore  are  many  such  ca.«es  on  record.  In  one,  the  particulars  of  which  arc 
detailed  at  p.  79  of  my  Croonian  Lectures,  and  referred  to  at  p.  91  of  Lecture  VI, 
a  mere  fli-xnre  of  the  neck  of  the  \v<>inb  had  prevented  tlie  escape  of  fluids  from  its 
cavity,  and  it  was  distended  by  the  accumulation  of  pus  witiiin  it  to  the  size  of  a 
hen's  egjij.  The  history  of  cases  of  inversion  of  tlni  womb,  as  detailed,  for  instance, 
in  Cross's  monoifraph  on  that  subject,  rejiresents  jirofnse  leuc<)rrba'a  as  one  of  its 
nevcr-fiiilini;  symjitoms,  sometimes  indeed,  thouijii  l)v  no  means  always,  succeeded 
by  a  serous  discharije,  almost  continuous  in  its  flow,  which  takes  tlie  |ilace  at  leniith, 
almost  or  alt<)a;ether,  of  the  previous  hemorrha2;es.  The  ]irnfus('  loss  of  blood  which 
accompanies  in  many  instances  the  small  mucous  polyju  of  tiie  cervix,  is,  on  the 
other  hand,  ample  evidence  that  hemorrhai^e  may  follow  irritation  of  the  neck  of 
the  womb,  as  well  as  mucous  discharge,  irritation  of  its  body  w  fundus. 


120  TREATMENT  OF  SYMPTOMS 

The  same  means  as  relieve  the  uterine  pain,  seldom  fail  to  dimin- 
isli  the  irritability  of  the  bladder  by  which  it  is  often  attended,  and 
which,  after  the  first  more  acute  sjnnptoms  have  passed  away,  is 
very  generally  associated  with  abundant  phosphatic  deposits  in 
the  urine.  Small  doses  of  hydrochloric  acid,  with  "tincture  of  hen- 
bane and  the  extract  and  decoction  of  pareira,  are  the  most  ser- 
viceable. So  long:  as  there  is  much  pain  or  much  uterine  tender- 
ness, no  local  applications  nor  vaginal  injections  will  be  of  service, 
except  such  as  are  simply  soothing,  as  tepid  water;  and  for  the 
same  purpose  the  tepid  hip-bath  may  be  found  of  benefit.  While 
these  measures  are  employed,  absolute  rest  for  a  time  is  needed, 
though  it  must  never  be  forgotten,  in  the  treatment  of  uterine 
ailments,  that  there  are  certain  positive  evils  to  which  prolonged 
rest  exposes  a  patient,  both  by  the  general  interruption  of  her 
health,  and  also  by  the  almost  inevitable  direction  of  her  thoughts, 
during  the  days  of  seclusion  from  her  ordinary  pursuits  and  ordi- 
nary amusements,  to  the  seat  of  suffering.  At  the  same  time  much 
prudence  is  necessary  in  breaking  through  restrictions  ;  and  even 
for  months  after  the  patient  is  convalescent,  the  approach  of  a 
menstrual  period,  the  presence  of  menstruation,  and  the  first  few 
days  after  its  cessation,  are  seasons  when  every  precaution  must 
be  most  strictly  observed. 

If  promptly  met,  the  symptoms  sometimes  pass  away  gradually, 
but  uninterruptedly  ;  though  the  tendency  to  relapse  which  each 
menstrual  period  brings  with  it,  or  which  some  very  slight  impru- 
dence suffices  to  occasion,  is  one  of  the  most  disappointing  features 
of  these  cases.  After  several  such  misadventures,  we  find  the 
uterus  not  only  enlarged  and  less  movable  than  natural,  but  its 
tissue  generally  feels  harder,  and  the  cervix  in  particular  presents 
this  character.  Leeches  will  still  do  something  in  many  instances 
towards  removing  this  condition  ;  though  it  is'  in  general  inexpe- 
dient to  apply  more  than  two  at  a  time,  and  the  result  of  their 
emploj^ment  must  settle  the  question  as  to  the  frequency  of  their 
repetition.  In  these  cases  the  bichloride  of  mercury  steadily  em- 
ployed for  many  weeks  has  seemed  to  me  preferable  to  any  other 
remedy,  exercising  a  decided  influence  in  reducing  the  enlarge- 
ment and  diminishing  the  induration  of  the  organ,  while  it  neither 
irritates  the  bowels  nor  affects  the  mouth,  as  other  mercurial  prep- 
arations, nor  disorders  the  digestion,  nor  produces  sleeplessness, 
both  of  which  evils  are  incidental  to  the  employment  of  iodide  of 
potassium.  I  prefer  giving  it  in  the  form  of  pill,  with  a  few  grains 
of  extract  of  hemlock,  and  if  this  be  taken  in  the  course  of  dinner 
or  luncheon,  all  risk  of  irritating  the  digestive  organs  is  avoided, 
a  matter  of  no  slight  importance,  where,  as  in  these  cases,  the 
appetite  is  fickle.  Some  kind  of  tonic  is  often  needed,  and  few 
are  so  little  likely  to  disagree  as  the  liquor  cinchonse.  If  the  bowels 
become  constipated,  or  the  liver  gets  out  of  order,  accidents  very 
apt  to  liappen,  suspension  of  the  tonic  for  a  day  or  two,  and  an 
aperient  with  two  or  three  grains  of  blue  pill,  or  a  pill  containing 


OF    CHRONIC    UTERINE    INFLAMMATION.  121 

a  grain  and  a  half  of  gray  powder,  of  watery  extract  of  aloes,  and 
of  extract  of  henbane,  will  usually  remove  the  symptoms. 

Pain  in  either  iliac  region  is  a  very  frequent  attendant  on  this 
condition.  A  small  blister  will  generally  eiiectuall}'  relieve  it;  or 
if  the  pain  be  scarcely  so  severe  as  to  necessitate  the  cm])loyment 
of  a  remedy  from  which  patients  usually  shrink,  a  liniment  of 
belladonna,  aconite,  and  soap  liniment,  maybe  employed  instead.^ 

Long  after  other  symptoms  have  passed  away,  or  have  at  least 
been  very  greatly  mitigated,  there  remains  a  disposition  to  exces- 
sive menstruation,  and  also  to  profuse  leucorrlucal  discharges,  due, 
I  believe,  to  the  persistence  of  congestion,  not  of  the  uterine  sub- 
stance only,  but  of  the  lining  membrane  of  the  womb  in  particular. 
This  is  a  state  of  things  for  which  chalybeate  preparations  are 
generally  the  best  remedy,  and  I  know  none  better  than  the  com- 
pound sulphate  of  iron,  sulphate  of  magnesia,  and  sulphuric  acid, 
which  I  mentioned  some  time  ago.^  Another  remedy  which  I 
have  tried  with  advantage  on  Dr.  Tyler  Smith's  recommendation, 
as  specially  adapted  to  cases  where  menorrhagia  is  a  prominent 
symptom,  is  a  compound  of  alum  with  sulphate  of  iron.  He 
speaks  of  a  compound  salt^  which  he  has  employed  for  his  hospi- 
tal patients ;  but  even  in  the  rough  form  of  extempore  prescrip- 
tion, it  has  seemed  to  me  very  useful. 

But,  besides  internal  medicines,  various  external  remedies,  such 
as  hip-baths  and  vaginal  injections,  may  be  emplo^-ed  with  advan- 
tage in  the  more  chronic  stages  of  this  affection.  It  is  true  that 
we  who  now  believe  the  main  source  of  the  discharge  in  these  cases 
to  be  not  the  vagina,  but  the  uterus,  cannot  anticipate  so  much 
good  from  their  use  as  was  reckoned  on  l)y  our  predecessors,  who 
imagined  that  the  fluid  injected  into  the  vagina  came  into  direct 
contact  with  the  secreting  surface  whence  the  leucorrhoeal  discharge 
was  furnished.  Still,  mere  purposes  of  cleanliness  furnish  one 
very  obvious  reason  why  injections  should  be  employed  in  every 
case  of  abundant  leucorrhoea ;  while  in  addition  it  may  be  borne 
in  mind,  that  almost  always,  when  the  ailment  is  of  long  standing, 
a  part  of  the  discharge  is  poured  out  from  the  vaginal  Avails,  and 
some  also  from  the  follicles  of  the  cervix,  on  both  of  which  it  may 
be  expected  that  the  medicated  fluid  will  act  more  or  less  ener- 
getically. The  injection  also  will  serve  to  give  tone  to  the  relaxed 
vagina,  and  thus  to  counteract  the  disposition  to  prolapsus,  which 
is  an  almost  constant  sequela  of  uterine  inflammation,  while  if 
fluid  be  used  abundantly,  or  its  injection  continued  for  several 

1  (Xo.  10.) 

R     Extr.  Bollaclonna3, ^fis 

Tiiict.  Aconiti  (Fleming's),      .     .     .     ,::;iv 

Lin.  Sa|)onis,  CO., 3Js.< — M.  ft.  Lininiontum. 

For  this  very  useful  formuhi  I  nm  indebted  to  a  jmper  of  Dr.  Oldliam's,  "  On  the 
Use  of  IJichlorido  of  Mercury  in  Hypertrophy  of  the  Uterus,"  Guy's  Hosjniul  lie- 
ports,  2(\  Series,  vol.  vi,  pt.  i,  p.  IGl. 
2  See  Formula  No.  1,  p.  46. 
'  The  Putliology  and  Treatment  of  Leiicoii'haay  8vo. ,  1855,  p.  11)3. 


122  •         TREATMENT     OP    THE     LEUCORRHCEA. 

minutes  at  a  time,  it  is  also  not  without  decided  influence  on  the 
body  and  cavity  of  the  womb  themselves. 

For  any  such  ends  to  be  gained,  however,  it  is  essential  that 
injections  be  employed  much  more  eiEciently  than  can  be  done  by 
means  of  the  ordinary  syringes,  or  of  the  India-rubber  bottles 
which  are  commonly  used.  Dr.  Evory  Kennedy's  ingenious  syringe, 
or  even  the  cylindrical  pump  syringe,  which  is  a  more  convenient 
application  of  his  original  idea,  both  require  a  degree  of  strength 
of  hand  which  few  women  possess ;  but  a  recent  modification  of 
the  ordinary  syringe,  which  I  have  seen  at  Mr.  Ferguson's,  instru- 
ment-maker, of  Giltspur  Street,  furnished  with  a  foot,  that  keeps 
it  steady  without  the  use  of  both  hands,  appears  to  me  to  obviate 
every  difficulty  that  was  experienced  in  the  use  of  the  other  instru- 
ments. Still  more  efficacious,  however,  is  the  douche,  which  indeed 
I  am  accustomed  to  employ  very  generally  in  hospital  practice,  in 
all  cases  where  the  uterine  cavit\'  appears  to  be  the  source  of  the 
discharge.  The  only  drawback  from  its  use  is,  that  there  is  a  kind 
of  fuss  in  getting  it  ready,  which  induces  me  in  private  practice 
usually  to  substitute  for  it  the  hip-bath.  By  dissolving  a  quarter 
of  a  pound  of  alum  in  the  water  of  the  bath,  a  very  good  astrin- 
gent is  obtained.  If  the  patient  is  apprehensive  of  taking  cold, 
the  bath  may  at  first  be  warmed  to  about  70°  ;  and  by  degrees  its 
temperature  may  be  reduced  till  it  is  taken  quite  cold.  The  morn- 
ing is  the  most  convenient  time  for  using  it,  and  the  patient  should 
remain  in  at  least  ten  minutes,  in  order  to  derive  any  important 
benefit. 

With  reference  to  vaginal  injections,  the  point  of  most  impor- 
tance in  their  composition  is,  that  they  should  be  inexpensive  and 
readily  prepared  by  the  patient  herself.  The  dilute  lead  lotion, 
which  can  be  readily  made  from  the  Goulard  extract,  lotions  of 
zinc,  or  of  alum,  all  have  their  advantages  ;  while  two  drachms  of 
tannin,  and  half  an  ounce  of  alum  dissolved  in  a  quart  of  water, 
form  as  powerful  an  astringent  as  the  decoction  of  oak-bark  and 
alum  lotion,  which  requires  much  time  for  its  preparation.^ 

Though  in  the  great  majority  of  instances  these  measures  suffice 
for  the  gradual  recovery  of  the  patient,  yet  to  this  rule  there  are 
occasional  exceptions,  and  local  applications  are  sometimes  neces- 
sary to  bring  about  the  healing  of  an  ulcerated  or  abraded  condi- 
tion of  the  OS  uteri,  which  may  have  persisted,  unafiected  or  but 
little  modified,  by  the  general  treatment. 

The  vivid  red  appearance  of  the  os  uteri,  associated  with  more 

1  A  peculiar  form  of  uterine  leucorrhoea,  limited  in  its  occurrence  to  the  aged, 
and  associated  with  dilatation  of  the  cavity  and  atrophy  of  the  walls  of  the  uterus, 
has  heen  described  h}-  Dr.  Matthews  Duncan,  in  the  Edinhirgh  Medical  Journal, 
March,  1860.  Its  characteristic  symptoms  appear  to  be  peculiar  lumbar  and  pelvic 
pain,  accompanied  by  a  sense  of  constriction,  and  the  discharge  of  muco-pus.  Its 
cure  seems  to  require  the  dilatation  of  the  contracted  internal  os  by  the  sound,  and 
the  application  of  nitrate  of  silver  to  the  interior  of  the  womb.  I  believe  that  I 
have  met  with  this  condition  on  one  or  two  occasions,  but  the  patients  having  their 
minds  relieved  with  reference  to  the  existence  of  uterine  cancer,  preferred  putting 
up  with  the  discomfort  to  submitting  to  treatment  for  its  cure. 


LOCAL  TREATMENT  OF  ULCERATION  OF  OS.     123 

or  less  extensive  abrasion  of  its  surface,  and  a  slightly  granular 
appearance,  which  is  not  infrequently  met  with  during  the  more 
active  stages  of  these  affections,  for  the  most  part  alters  its  char- 
acter, loses  its  vivid  color,  and  finally  disappears  under  tlie  local 
depletion  which  the  state  of  the  uterus  generally  calls  for.  Some- 
times, however,  it  continues,  its  granulations  become  large,  soft, 
very  vascular,  and  bleed  easily,  while  the  surface  furnishes  a  very 
considerable  quantity  of  glairy  discharge.  In  this  case  the  os  and 
cervix  uteri  are  usually  tender,  sexual  intercourse  is  painful,  and 
is  often  followed  b}^  a  little  bleeding.  This  condition,  like  that 
swollen  and  granular  state  of  the  palpebral  conjunctiva  witli  which 
we  are  familiar  in  the  purulent  ophthalmia  of  young  children,  is 
generally  much  benefited  by  extensive  scarifications,  which  may 
be  followed  by  the  daily  application  of  powdered  alum  on  a  piece 
of  cotton-wool,  or  by  the  introduction  of  a  piece  of  cotton-wool 
soaked  in  a  strong  solution  of  alum.  By  means  of  a  piece  of  thread 
tied  to  the  cotton-wool  it  can  be  removed  by  tlie  patient  herself  in 
the  course  of  a  few  hours,  though  it  must  always  be  introduced 
through  the  speculum.  In  the  greater  number  of  instances,  the 
state  of  the  os  uteri  becomes  so  much  improved  in  four  or  five 
days  that  this  mode  of  treatment  may  be  then  dispensed  with,  and 
the  sedulous  employment  of  strong  astringent  injections  will 
usually  suffice  to  complete  the  patient's  cure.  When  tliis  is  not 
the  case,  but  the  morbid  condition  still  continues,  more  powerful 
applications  may  be  needed.  The  nitrate  of  silver  is  not  in  gen- 
eral suitable  in  these  cases,  for  its  application  is  often  followed  by 
pain  and  also  by  bleeding.  The  acid  nitrate  of  mercury,  both  in 
this  instance,  and  also  whenever  a  strong  caustic  is  required,  has 
seemed  to  me  the  most  useful  ap})lication  ;  and  with  moderate  care 
its  employment  is  unattended  by  risk.  When  it  is  used,  however, 
the  patient  must  lie  on  her  back,  and  one  of  Coxeter's  bivalve 
speculums  being  introduced  so  as  thoroughly  to  expose  the  os  and 
include  the  cervix,  a  little  cotton-wool  must  be  carefully  disposed 
all  round  the  edge  of  the  speculum,  so  as  to  .'ibsorb  any  of  the 
superfluous  acid,  and  to  prevent  it  from  running  down  outside  the 
speculum,  and  thus  injuring  the  vagina.  A  brush  can  easily  be 
extemporized  by  trimming  a  little  piece  of  cotton-wool  after  it  is 
placed  in  the  holder,  and  the  whole  diseased  surface  may  then  be 
painted  over  wnth  the  caustic,  which  immediately  forms  upon  it  a 
white  eschar.  A  piece  of  dry  cotton-wool  now  pressed  against  the 
part  will  absorb  any  superfluous  caustic:  the  little  strips  placed 
around  the  edge  of  the  speculum  may  then  be  removed  and  the 
speculum  withdrawn.  An  additional  precaution,  however,  which 
it  is  well  to  take,  consists  in  introducing,  before  the  withdrawal 
of  the  speculum,  a  piece  of  moistened  cotton-wool  up  to  the  os 
uteri,  whence  it  may  be  removed  in  the  course  of  a  few  hours  by 
the  ])atient.  It  is  seldom  that  either  pain  or  bleeding  follows  this 
application  ;  and  at  the  end  of  a  Aveek  the  eschar  will  usually  be 
separated,  the  surface  will  be  found  to  have  lost  its  fungous  char- 
acter, and  cicatrization  to  be  commencing  at  its  edges.     A  zinc 


124         TREATMENT  OF  ULCERATION  OF  OS. 

lotion  of  about  five  grains  to  the  ounce,  or  the  bhick  wash  em- 
ployed as  a  vaginal  injection  twice  a  day,  will  now  generally  be 
sufficient ;  but  sometimes  the  surface  puts  on  an  indolent  character 
again,  and  it  may  then  be  expedient  to  touch  it  once  or  twice  with 
the  nitrate  of  silver,  and  I  have  occasionally  found  it  necessary  to 
repeat  the  application  of  the  nitrate  of  mercury. 

Another  state  which  I  have  but  rarely  met  with,  but  which  seems 
usually  to  call  for  caustic  applications,  is  one  in  which  the  os  uteri 
is  the  seat  of  a  distinct  ulcer,  with  sharply  cut  edges,  its  surface 
apparently  a  little  depressed  below  the  adjacent  tissue,  partially 
covered  by  a  thin  layer  of  dirty  yellowish  lymph,  but  red  and 
bleeding  on  its  removal.  This  condition  has  usually  come  under 
my  notice  in  women  whose  previous  history  afforded  evidence  of 
syphilitic  infection  some  months  before,  and  it  has  generally  dis- 
appeared rapidly  under  one  or  two  applications  of  the  nitrate  of 
mercury. 

Besides  the  two  above-mentioned  conditions  of  the  os  uteri, 
which  are  those  that  oftenest  seem  to  call  for  caustic  applications, 
I  have  in  other  instances  employed  them  almost  empirically,  where 
I  have  found  ulceration  or  some  allied  morbid  condition  of  the  os 
uteri  to  exist  independent  of  any  appreciable  disease  elsewhere, 
or  where  a  morbid  state  of  the  os  has  persisted  after  the  other 
symptoms  of  uterine  ailment  have  been  subdued.  Neither  the 
one  nor  the  other  of  these  cases  has,  however,  seemed  to  me  of 
frequent  occurrence. 

Although  I  expressed  my  dissent  from  the  opinion  that  the 
sole,  or  indeed,  in  the  majority  of  instances,  the  principal  source 
of  leucorrhffial  discharge,  is  the  follicular  structure  of  the  cervix 
uteri,  it  yet  must  not  be  forgotten  that  a  very  copious  secretion 
may  l)e  poured  out  from  that  part,  and  that,  in  some  instances,  as, 
for  example,  in  pregnancy,  the  discharge  may  be  almost  exclu- 
sively derived  from  it.  The  whole  glandular  apparatus  of  the  cervix 
uteri  undergoes  a  remarkable  development  during  pregnancy,  and 
exercises  its  secretory  function  with  an  activity  which  contrasts  re- 
markably with  its  non-gravid  condition  ;  and  then  also  many  of  the 
mucous  folicles  attaining  an  unusual  size  without  opening  and 
giving  exit  to  their  contents,  form  those  bodies  which  are  usually 
known  under  the  name  of  the  I^abothian  bodies."^ 

But  besides  pregnancy,  tliere  are  some  other  conditions,  not 
very  clearly  understood,  though  generally,  I  believe,  connected 
with  some  previous  irritation  of  the  body  of  the  uterus  itself,  such 
as  miscarriage  leaves  behind,  or  as  may  be  produced  by  habitual 

1  Further  incidental  remarks  on  the  much  debated  question  of  the  nature  of 
these  Nabotliian  bodies  will  be  found  in  Lecture  XIV,  under  the  head  of 
"Glandular  Polypi,  and  Mucous  Cysts  of  the  Uterus."  It  may  suffice  now,  how- 
ever, to  state  that  the  reasons  for  regarding  them  as  the  obstructed  mucous  follicles 
of  the  cervix,  which  are  assigned  by  M.  Huguier,  at  p.  258  of  his  paper  "  Sur  les 
Kystes  de  la  Matrice,"  &c.,  in  voL.i,  of  the  Memoires  de  la  Soc.ietc  de  Chirnrriie, 
-seem  to  me  quite  conclusive.  The  same  view  of  their  nature  is  taken  also  by  Dr. 
Hennig,  o}^.  cit.  p.  63. 


TREATMENT    OF    CERVICAL    LEUCORRHCEA.  125 

scxnal  excesses,  as  in  the  case  of  prostitutes,  in  wliich  the  cervical 
ghands  become  enlarged,  and  pour  out  an  abundant  transparent, 
albuminous  discharge.  In  some  instances,  the  discharge  collects 
witliin  the  cervical  canal,  and  escapes  in  gushes  at  short  intervals. 
In  other  cases  the  discharge  is  continuous,  and  may  be  seen  issu- 
ing in  great  abundance  from  the  os  uteri,  which  is  usually  found 
open,  its  lips  large  but  soft,  and  not  tender,  and  a  granular  or 
abraded  condition  of  their  surface  as  often  absent  as  present,  while 
the  body  of  the  organ  is  in  general  quite  movable,  and  not  larger 
than  natural.  Between  this  condition  and  that  in  which  there  is 
a  positive  cyst  formation  in  the  substance  of  the  cervix  uteri,  the 
ditferencc  is,  I  believe,  rather  of  degree  than  of  kind.  The  dis- 
tinction between  leucorrhoea  from  this  source,  and  that  Avhich  is 
furnished  from  higher  up  in  the  uterine  cavity,  is  furnished  by 
the  abundance  of  the  discharge  in  the  former  cases,  its  peculiar 
transparency  and  tenacity,  and  the  frequent  presence  of  the  Ka- 
bothian  bodies  on  the  lips,  or  about  the  edges  of  the  os.  In  this 
case,  too,  in  spite  of  the  long  continuance  of  the  leucorrha'a,  it  is 
generally  unaccompanied  hy  the  graver  forms  of  functional  dis- 
order of  the  uterus,  such  as  menorrhagia,  dysmenorrhea,  and 
ovarian  pain;  while  it  is  not  infrequently  associated  with  a  state 
of  irritation  of  Cow^per's  glands,  which  pour  out  an  increased  dis- 
charge, or  even  w^ith  obliteration  of  their  duct  on  one  or  other 
side,  and  accumulation  of  their  contents  so  as  to  form  a  small 
encysted  tumor  at  the  inner  and  lower  part  of  the  labium. 

I  believe  this  ailment,  which  is  essentially  chronic  in  its  course, 
to  be  of  rare  occurrence.  It  certainly,  in  its  severer  forms,  is 
very  difficult  of  cure,  and  though  rather  an  annoying  infirmity 
than  a  serious  disease,  I  have  seen  one  case  where  the  complete 
failure  of  the  patient's  health  seemed  to  be  due  entirely  to  the 
abundant  secretion,  which  no  means  succeeded  in  checking. 

The  treatment  which  these  cases  require  is  almost  entirely  local. 
Something  may  be  done  by  astringent  lotions  of  various  kinds, 
and  es})ecially  by  such  lotions  wdien  employed  by  means  of  the 
douche  ;  though  you  must  not  forget  that  the  douche  is  inappli- 
cable whenever  a  sus})icion  is  entertained  of  the  existence  of  preg- 
nancy. Astringent  hip-baths,  too,  are  of  service;  while  during 
the  persistence  of  the  discharge,  it  is  expedient  that  sexual  inter- 
course be  but  rarely  indulged  in. 

I  have  found  benefit  in  some  cases  from  the  introduction  of 
dossils  of  cotton-wool  steeped  in  solution  of  tannin,  or  covered 
with  powdered  alum,  and  ap[)lied  by  means  of  the  s[)eculum  to 
the  OS  uteri ;  but  I  have  made  less  use  than  perhaps  I  ought  to 
have  done  of  tlie  injection  of  astringent  fluids  into  the  cervical 
canal  itself  A  very  convenient  contrivance  for  this  purpose,  con- 
sisting of  a  very  small  elastic  bottle  attached  to  a  carved  silver 
canula,  is  to  be  had  of  all  instrument-makers.  In  some  obstinate 
cases  I  have  cauterized  the  whole  of  the  interior  of  the  cervix 
with  nitrate  of  silver,  by  means  of  Lallemand's  portecaustique, 
but  without  advantage.     It  seems  as  if  in  these  cases  the  action 


126  PROLAPSUS    UTERI. 

of  the  nitrate  of  silver  was  expended  on  the  copious  secretion, 
and  scarcely  reached  the  cervical  follicles  themselves.  Something 
may  probably  be  done  to  avoid  this  evil,  by  the  employment  of 
the  douche,  or  of  very  abundant  vaginal  injections  to  clear  the 
canal  of  the  cervix  to  some  extent  just  before  the  caustic  is  em- 
ployed. I  am  disposed  to  think,  however,  that  in  the  most  obsti- 
nate cases  it  may  be  expedient  to  adopt  a  suggestion  of  M. 
Iluguier,  of  which  I  have  but  small  experience,  though  I  have 
followed  it  with  benefit  on  two  or  three  occasions.  He  is  accus- 
tomed^ to  scarify  the  interior  of  the  cervical  canal  with  a  small, 
curved,  narrow-bladed,  blunt-pointed  bistoury  before  introducing 
the  caustic.  The  previous  scarification  exposes  the  more  deep- 
seated  follicles,  which  would  otherwise  altogether  escape  the  action 
of  the  remedy ;  and  while  M.  Huguier  states  that  he  has  never 
known  any  mischief  follow  this  proceeding,  he  has  by  its  repetition 
two  or  three  times  eflected  the  cure  of  cases  that  resisted  every 
other  mode  of  treatment. 


^LECTURE  IX. 

MISPLACEMENTS  OF  THE  UTERUS. 

Prolapsus  Uteri.  Reasons  for  the  mobility  of  the  uterus,  and  consequent  variety 
of  misplacements  to  which  it  was  liable.  Various  degrees  of  prolapsus,  and 
arrangements  by  which  its  occurrence  is  o{)posed ;  its  causes,  tendency  to  in- 
crease, changes  in  the  uterus,  and  in  adjacent  parts.  Complete  Prolapse,  or 
Procidentia. 

Prolapse  of  the  Vagina  ; — its  relation  to  prolapse  of  the  womb — may  occur  in 
connection  with  hypertrophy  of  walls  of  canal ;  peculiarities  of  this  form,  and 
hypertrophy  of  cervix  uteri  which  it  produces.  Prola]ise  of  anterior,  and  of 
posterior  wall,  with  descent  of  bladder  and  of  rectum :  its  causes,  character,  and 
mode  of  production. 

Among  the  many  wonderful  adaptations  of  means  to  an  import- 
ant end  with  which  the  study  of  anatomy  makes  us  acquainted,  not 
the  least  remarkable  is  the  contrivance  by  which  the  uterus  is  sus- 
pended in  the  pelvic  cavity,  so  movable  as  to  escape  any  rude 
shocks  from  without,  or  any  inconvenience  from  the  varying  con- 
ditions of  the  surrounding  viscera,  and  yet  so  tethered  to  its  place 
as  to  insure  its  enlargement  going  on,  if  pregnancy  occurs,  in  such 
a  direction  as  shall  avoid  needless  discomfort  to  the  person,  or 
pressure  upon,  and  disorder  of  the  functions  of  other  organs.  But 
this  very  mobility,  without  which  pregnancy  would  be  a  season  of 
uninterrupted  suftering,  and  even  sexual  intercourse  almost  im- 
possible, naturally  exposes  the  womb  to  the  risk  of  changes  in  its 
position,  such  as  may  themselves  become  the  source  of  inconve- 

1  See  the  third  of  his  "Lectures  on  Uterine  Catarrh,"  in  Gaz.  des  Hojntaux, 
1847,  p.  379. 


PROLAPSUS     UTERI.  127 

nience,  and  as  call  more  frequently  than  almost  any  uterine  ail- 
ments for  medical  interference. 

It  is  obvious  enough,  that  an  organ  suspended  within  a  capacious 
cavity  by  means  of  supports  which  are  themselves  yielding,  must 
be  very  likely  to  be  displaced  by  comparatively  trivial  causes.  In 
the  case  of  the  uterus,  too,  the  risk  of  its  displacement  is  further 
increased  by  the  circumstance,  that  its  weight  and  size  are  subject 
to  variations,  and  that  the  very  causes  wliich  tend  to  render  it 
heavier  and  larger  than  natural,  liave  often  the  further  eflect  of 
diminishing  the  powder  of  those  supports  by  which  it  is  retained  in 
its  natural  position.  The  tendency  to  misplacement,  too,  is  further 
encouraged  by  the  pressure  from  above  of  the  superincumbent 
viscera,  and  by  all  those  muscular  exertions  which  a  person  cannot 
avoid  making  in  walking,  in  lifting  weights,  or  even  in  efforts  at 
defecation. 

All  these  causes,  indeed,  tend  to  produce  displacement  in  one 
direction — namely,  downwards ;  and  accordingly,  in  all  but  some 
very  rare  instances  of  uterine  misplacement,^  the  organ  is  thrown 
lower  down  than  natural,  though  there  are  some  causes  which 
likewise  incline  the  fundus  of  the  uterus  either  backwards  or  for- 
wards, and  thus  produce  its  retroversion,  or  anteversion,  instead  of 
its  simple  prolapse. 

Prolapse  or  descent  of  the  womb  is  so  much  the  most  common 
form  of  misplacement  of  the  organ,  that  I  will  first  notice  it  and 
those  allied  conditions  in  which  either  the  rectum  or  the  bladder 
becomes  prolapsed,  dragging  in  some  cases  the  uterus  with  it,  and 
will  afterwards  call  your  attention  to  those  modifications  of  its 
situation  in  which  its  fundus  is  either  thrown  backwards  or  tilted 
forwards. 

Prolapsus  of  the  womb,  then,  which  is  a  common  result  of  any 
cause  that  either  increases  the  weight  of  the  oro:an  or  diminishes 
the  strength  of  its  supports,  may  exist  in  three  different  degrees, 
for  which  different  names  have  been  proposed,  but  which  it  will,  I 
think,  be  most  convenient  to  designate  simply  as  the  Jirst,  second, 
and  third  degrees  of  prolapse. 

In  prolapsus  of  the  first  degree,  the  organ  is  merely  situated 
lower  than  natural,  but  still  preserves  its  proper  direction,  its  axis 
corresponding  with  that  of  the  pelvic  brim,  and  this  even  though  it 
should  be  so  low  that  its  cervix  rests  upon  the  fioor  of  the  vagina. 

In  prolapsus  of  the  second  degree,  the  uterus  is  situated  with 
its  fundus  directed  backwards,  its  orifice  forwards,  so  that  its  long 
axis  corresponds  with  the  axis  of  the  pelvic  outlet. 

In  prolapsus  of  the  third  degree,  or,  as  it  is  often  termed, 
jjrccidentia  of  the  uterus,  the  organ  lies  more  or  less  completely 
externally,  hanging  down  beyond  the  vulva,  though  it  generally 

1  The  protornatural  elevation  of  the  uterus  is  not  only  a  rare  condition,  but  also 
one  which  of  itself  gives  rise  to  no  peculiar  or  characteristic  syni|)tonis.  Some 
remarks  on  its  diagnostic  import  in  douhtful  cases  of  affection  of  the  uterus  or  its 
appendages  will  be  found  in  Lecture  Xlll. 


128  MEANS    BY    WHICH 

admits  of  being  replaced  within  the  vagina,  if  not  of  being  alto- 
gether restored  to  its  natural  position. 

Now  the  first  question  that  suggests  itself  to  us  with  reference  to 
this  accident,  concerns  the  manner  in  which  it  is  brought  about, 
and  the  mechanism  which  must  be  disordered  before  its  occurrence 
becomes  possible.  The  ofl-hand  reply,  that  the  womb  is  main- 
tained in  its  natural  situation  by  its  ligaments,  and  that  their  weak- 
ening and  stretching  are  the  cause  of  its  prolapse,  is  neither  minute 
nor  correct  enough  to  be  of  much  service  to  us  in  practice.  The 
w^omb  is  not  merely  suspended  in  the  pelvis  by  the  duplicaturcs  of 
peritoneum  within  which  it  is  contained,  but  is  also  supported  in  its 
place  by  the  vagina,  on  which  it  rests  as  on  a  firm  though  elastic 
stem.  The  vagina  is  yielding  enough  to  allow  of  the  voluntary 
efforts  depressing  the  womb  to  the  extent  of  half  an  inch  or  an 
inch,  but  immediately  these  efibrts  cease,  the  organ  would  in  the 
healthy  state  resume  its  former  position,  while  any  further  descent 
of  the  womb  would  be  at  once  resisted  by  the  duplieatures  of 
peritoneum,  which  would  be  put  on  the  stretch.  In  the  liealthy 
virgin,  however,  the  support  afforded  by  the  vagina  is  very  consid- 
erable ;  for  instead  of  being  a  wide  canal  with  membranous  walls 
far  distant  from  each  other,  as  it  appears  in  so  many  anatomical 
drawings  and  preparations,  its  two  w^alls  lie  in  close  contact  with 
each  other,  and  thus  form  an  almost  solid  stem  for  the  uterus  to 
rest  upon.  The  curved  direction  of  the  vagina  further  lessens  the 
chances  of  misplacement  of  the  womb,  while  at  either  extremity 
the  vagina  is  strengthened  by  its  connection  through  the  medium 
of  the  pelvic  fascia  with  the  bladder  and  rectum  above,  and  by 
the  sphincter  which  surrounds  it  below,  as  well  as  by  the  other 
muscles  of  the  pelvic  floor,  and  by  the  perineal  fascia,  between  the 
two  layers  of  which  those  muscles  lie. 

By  these  arrangements  the  very  beginning  of  prolapsus  is  in  the 
healthy  virgin  altogether  prevented ;  but  let  habitual  leucorrhoea 
relax  the  vaginal  walls,  or  frequently  recurring  menorrhagia  dimin- 
ish their  resistance,  just  as  the  loss  of  blood  robs  all  tissues  of 
their  natural  resiliency,  and  you  will  at  once  see  that  the  first  step 
towards  the  production  of  prolapsus  uteri  is  already  taken.  While 
all  things  were  in  a  state  of  health,  the  connection  of  the  vagina 
with  the  rectum,  and  thereby  with  the  posterior  pelvic  wall,  would 
have  been  the  first  to  ofler  resistance  to  the  further  descent  of  the 
womb.  If  the  parts,  however,  are  lax  and  yielding,  this  slight 
resistance  will  soon  be  overcome,  and  the  anterior  attachments  of 
the  vagina  not  affording  any  more  serious  obstacle,  the  upper  part 
of  the  canal  will  become  inverted  as  the  uterus  descends,  and  will 
readily  allow  it  to  occupy  a  position  from  an  inch  to  an  inch  and 
a  half  lower  than  its  natural  situation.  In  many  instances  the 
organ  remains  in  this  position,  its  cervix  a  little  above,  or  even 
resting  on  the  posterior  vaginal  wall,  for  its  further  descent  is 
opposed  by  the  various  duplicaturcs  of  its  peritoneal  investment. 
First,  the  posterior  part  of  the  broad  ligaments,  and  the  utero-sacral 
ligaments  must  be  put  on  the  stretch,  and  then  the  middle  part  of 


PROLAPSUS    IS     PREVENTED.  129 

the  broad  ligaments,  before  any  considerable  stress  will  be  expe- 
rienced by  the  utero-vesical  ligaments,  or  by  the  anterior  fold  of 
the  broad  ligaments,  and  it  is  to  tlie  circumstance  of  the  posterior 
attachments  of  the  uterus  tying  it  down  so  much  more  closely 
than  the  anterior  that  we  must  in  groat  measure  attribute  the 
tendency  of  the  fundus  uteri  to  fall  back  into  the  hollow  of  the 
sacrum  in  every  case  of  prolapse  of  the  organ.  The  round  liga- 
ments of  the  uterus  have  no  share  in  preventing  descent  of  the 
womb  ;  their  office  seems  to  have  reference  to  the  development  of 
the  organ  during  pregnane}'  rather  than  to  its  situation  in  the 
unimpregnated  state,  and  the  organ  must  not  merely  be  prolapsed, 
but  must  be  procident  far  beyond  the  external  parts,  before  the 
round  ligaments  can  be  at  all  put  on  the  stretch,  or  can  be  in  the 
least  affected  by  its  changed  position. 

As  has  been  already  mentioned,  descent  of  the  uterus  is  not 
often  the  consequence  of  mere  weakening  of  its  supports,  but  in 
the  great  majority  of  instances  the  same  cause  as  diminishes  the 
resistance  increases  at  the  same  time  the  superincuml)ent  weight. 
The  leucorrhoea  or  the  menorrhagia  which  deprives  the  vagina  of 
its  tone,  is  often  associated  with  actual  uterine  disease,  and  the 
organ,  enlarged  by  clironic  inflammation  or  its  consequences,  is 
more  prone  than  in  a  healthy  person  to  sink  below  its  natural 
position.  Such  is  the  history  of  most  of  the  cases  in  which  ])ro- 
lapsus  uteri  takes  place  in  unmarried  women,  or  in  those  who  have 
not  recentl}'  given  birth  to  children  ;  and  in  such  cases,  with  the 
cure  of  the  intlammation  and  the  reduction  in  bulk  of  the  hyper- 
trophied  organ,  the  vagina  will  once  more  regain  its  proper  tone, 
and  the  womb,  which  had  been  situated  only  an  inch  or  an  inch 
and  a  half  from  the  vulva,  will,  as  it  were  spontaneously,  resume 
its  {tropor  position  high  up  in  the  pelvic  cavity. 

In  most  cases,  however,  it  is  not  in  single  but  in  married  women 
that  prolapsus  takes  place,  and  in  them  it  very  generally  succeeds 
to  aljortion  or  to  labor.  Everj'thing  in  these  circumstances  con- 
spires to  favor  the  occurrence  of  the  malposition,  for  the  womb  is 
greatly  increased  in  weight  at  the  very  time  when  the  vagina  has 
lost  most  of  its  power  of  resistance,  while  the  duplicatures  of  the 
peritoneum  have  been  so  recently  put  on  the  stretch  by  the  die- 
tended  uterus  as  to  be  but  little  able  to  prevent  even  the  more 
advanced  degrees  of  misplacement.  In  not  a  few  instances,  too, 
the  tendency  to  this  accident  is  still  further  increased  by  the  per- 
ineum having  been  lacerated,  and  by  the  wliole  posterior  wall  of 
the  vagina  having  thus  been  deprived  of  its  natural  sup]M)i-t  by 
the  tearing  of  the  fascia  and  muscles  of  the  perineum,  an  accident 
which  has  the  additional  effect  of  giving  to  the  canal  a  perpen- 
dicular instead  of  a  curved  direction. 

The  general  rule  of  the  coexistence  in  cases  of  ju'olaj^sns  uteri  of 
increased  weight  of  the  organ  with  diminished  power  of  its  sup- 
ports, is  not,  however,  without  occasional  exce]>lion.  Even  in  a 
previously  healthy  person,  a  sudden  and  violent  eti'ort,  such  as  the 
attempt  to  lift  a  heavy  weight,  may  sometimes  cause  the  uterus  to 

9 


130       VARIOUS  CAUSES  OF  PROLAPSUS  UTERI. 

prolapse  beyond  the  external  parts,  just  as  in  another  person,  or  in 
the  other  sex,  a  similar  effort  might  produce  a  hernia.  But  while 
such  cases  call  for  no  further  remark,  the  occasional  occurrence  of 
prolapsus  of  the  womb  in  old  age,  in  spite  of  a  healthy  or  even  of 
an  atrophied  condition  of  the  organ,  and  in  the  absence  of  an}^  ex- 
citing cause,  requires  some  explanation.  This  explanation,  indeed, 
is  not  far  to  seek,  for  it  is  furnished  by  circumstances  peculiar  to 
that  period  of  life.  With  the  advance  of  years  the  fat  and  cellular 
tissue  which  give  their  rotundity  to  the  labia,  and  which  form  a 
sort  of  cushion  about  the  entrance  of  the  vagina,  become  entirely 
removed ;  and  instead  of  the  vulva  being  closed,  it  is  scarcely  con- 
cealed by  the  shrunken  parts.  The  fat  of  the  perineum  is  removed; 
the  levator  ani  becomes  atrophied  and  feeble,  and  the  vagina  grows 
shorter  as  well  as  smaller,  while  it  loses  its  muscularity,  and  the 
peritoneal  duplicatures  lose  their  resilience.  The  womb  may  now 
almost  spontaneously  become  prolapsed,  since,  though  shrunken 
instead  of  being  increased  in  size,  it  has  almost  completely  lost 
the  support  which  kept  it  in  its  proper  position.^ 

This  somewhat  tedious  explanation  of  the  different  conditions 
under  which  prolapsus  of  the  uterus  is  commonly  brought  about, 
shows,  I  think,  clearly  why  it  is  that  the  fundus  of  the  womb  is  so 
disposed  to  fall  backwards,  why  every  prolapsed  womb  is  to  a  great 
extent  retroverted  also.  You  see  that  the  anterior  uterine  liga- 
ments do  not  tie  the  organ  so  closely  in  its  place  as  the  posterior, 
and  that  consequent!}'  the  liability  of  the  womb  to  retroversion 
must  always  be  much  greater  than  to  anteversion.  You  see  also 
how  it  comes  to  pass  that  the  uterus,  when  once  prolapsed,  is  always 
extremely  likely  to  remain  so.  The  vagina  having  once  yielded 
so  as  to  allow  of  the  descent  of  the  womb,  can  hardly  be  expected 
to  recover  its  tone  while  the  patient  is  going  about  her  ordinary 
avocations,  and  the  uterine  ligaments,  subjected  to  dail}^  stress, 
can  scarcely  do  other  than  yield.  But  not  only  is  the  spontaneous 
cure  of  a  prolapsed  uterus  thus  rendered  very  unlikely,  but  the 
condition  has  a  constant  ten  !ency  to  pass  from  bad  to  worse,  and 
for  this  simple  reason,  that  the  pressure  of  the  intestines  from  above 
is  always  helping  to  increase  the  descent  of  the  uterus,  always  "fill- 
ing up  the  space  which  that  descent  leaves  vacant  in  the  pelvis. 
The  prolapse  of  the  posterior  wall  of  the  vagina,  if  at  all  consider- 
able, is  daily  aggravated  by  the  efforts  at  defecation,  and  thus  the 
womb,  pressed  on  from  above  by  the  intestines,  is  at  the  same  time 
drawn  downwards  by  the  vagina.  The  close  connection  between 
the  cervix  uteri  and  the  neck  of  the  bladder  is  a  temporary  obstacle 
to  the  complete  descent  of  the  womb,  while  at  the  same  time  it 
favors  the  retroversion  of  the  organ  ;  but  if  at  length  this  yields, 
the  urine  accumulating  in  the  bladder  distends  its  fundus  and  the 
anterior  vaginal  wall  into  a  pouch  which  drags  down  the  uterus 

1  By  far  the  best  account  of  the  mechanism  of  prohipsus  uteri,  and  which  I  have 
followed  in  the  text,  is  given  by  Kiwisch,  Klinische  Vort7-dge,  od  edition,  vol.  i,  p. 
171. 


CHANGES    WHICH    RESULT    FROM    PROLAPSUS    UTERI.       131 

in  front  just  as  the  prolapse  of  the  rectum  drags  it  down  behind; 
and  the  organ  now  soon  comes  to  lie  beyond  the  external  parts; 
the  case  being  thus  converted  into  one  of  procidentia  of  the  uterus, 
or  of  prolapse  in  the  third  degree. 

But  this  misplacement  of  the  womb  does  not  happen,  or  at  least 
occurs  comparatively  seldom  unaccompanied  by  other  alterations 
both  in  the  organ  itself  and  in  the  surrounding  parts.  The  womb, 
subjected  to  constant  and  unusual  irritation,  obeys  the  law  which 
we  observe  to  be  exemplified  in  almost  all  the  affections  to  which 
it  is  liable,  and  increases  in  size  by  a  process  of  simple  hypertro- 
phy, that  ditiers  from  the  enlargement  of  pregnancy  only  in  the 
somewhat  greater  density  of  the  tissue.  Tlie  neck  of  the  womb 
is  the  part  in  which  this  alteration  chiefly  takes  place;  for  it  is  the 
neck  which  is  exposed  to  the  most,  and  the  most  constant  irrita- 
tion. This  enlargement,  too,  occurs  both  in  length  as  well  as  in 
thickness ;  so  that  the  neck  of  the  womb  may  not  only  be  found 
nearly  of  the  thickness  of  the  wrist,  but  also  greatly  elongated, 
and  the  os  uteri  be  thus  approximated  to  the  pelvic  outlet,  not 
simply  by  the  general  descent  of  the  womb,  but  also  in  great 
measure  by  positive  growth  of  its  neck.  The  lips  of  the  uterus 
become  enlarged,  together  with  the  rest  of  the  womb,  and  the 
small  transverse  aperture  which  in  women  who  have  borne  chil- 
dren should  represent  the  orifice  of  the  womb,  becomes  converted 
into  a  wide  opening,  situated  deep  in  between  projecting  lips, 
whose  surface,  irritated  and  excoriated,  presents,  in  parts  at  least, 
a  vivid  red,  finely  granular  surface,  covered  by  a  copious  albumin- 
ous secretion.  How  much  this  enlargement  of  the  womb  must 
lessen  the  chances  of  the  organ  resuming  its  proper  situation  in 
the  pelvic  cavity,  is  obvious  without  any  remark  of  mine. 

There  are  limits,  however,  to  tins  increase  of  the  womb,  which 
seems  to  be  most  considerable  while  the  organ,  though  occasionally 
or  partially  procident,  yet  admits  of  being  replaced  in  the  vagina; 
and  in  these  circumstances  I  once  found  the  neck  of  the  womb 
measure  eight  inches  in  circumference  an  inch  above  the  os  uteri. 
In  this  instance,  however,  the  patient  had  nine  months  beibre 
given  birth  to  a  child;  and  the  uterus,  both  at  that  time  and  also 
for  three  years  previously,  liad  been  occasionally  procident;  so  that 
its  enormous  enlargement  was  probably  partially  due  to  the  im- 
perfect involution  of  the  organ  after  delivery.  At  first  it  seems 
almost  impossible  that  so  enormous  a  mass  could  pass  out  of  the 
vulva,  and  be  replaced  without  difficulty,  unless  the  perineum  were 
altogether  destroyed.  In  not  a  lew  cases,  however,  of  procidence 
of  the  uterus,  the  whole  pelvic  floor  completely  loses  all  power  of 
resistance  ;  so  that,  though  quite  uninjured,  itofi'ers  not  the  slight- 
est obstacle  to  the  misplacement  or  reposition  of  the  womb  ;  an 
occurrence,  which  as  might  be  expected,  is  most  frequent  in  cases 
where  the  accident  has  followed  soon  after  delivery  at  the  full 
period,  when  the  parts  are  already  stretched  and  weakened  by  the 
passage  of  the  fcetus. 

In  the  course  of  time  the  occasionally  protruding  womb  comes 


132  CHANGES    WHICH    OCCUR 

to  He  constantly  beyond  the  vulva,  though  this  procidentia  may 
still  for  years  continue  to  be  onl}^  partial ;  the  fundus  and  a  portion 
of  the  organ  remaining  within  the  pelvis,  while  the  neck  and  lower 
part  of  its  body  are  external.  In  most  instances,  however,  so  con- 
siderable a  degree  of  descent  of  the  womb  is  before  long  converted 
into  its  complete  procidentia  ;  the  vagina  becoming  inverted,  and 
forming  the  outer  walls  of  a  tumor,  at  the  lower  part  of  which  the 
Vomb  is  situated.  So  long  as  the  procidentia  is  incomplete,  this 
tunlor  is  somewhat  pyriform  in  shape,  its  base  being  directed  up- 
wards ;  but  afterwards,  as  it  increases  in  size,  it  assumes  an  oval 
form,  owing  to  more  or  less  of  the  bladder  being  drawn  down  into 
it  in  front,  and  of  the  rectum  also,  in  many  cases,  behind.  Its 
bulk  is  also  further  swelled,  in  numerous  instances,  by  the  small 
intestines  sinking  down  into  the  sac,  and  thus  adding  to  its  size 
till  it  equals  or  exceeds  that  of  the  adult  head.  In  a  preparation 
now  in  the  museum  of  St.  Bartholomew's  Hospital,  the  external 
tumor  measured  seven  inches  and  a  half  in  length  by  thirteen 
inches  in  circumference,  and  was  found  to  contain,  in  addition  to 
the  uterus  and  its  appendages,  the  bladder,  and  a  portion  of  the 
rectum  ;  no  less  than  five  feet  eight  inches  of  the  small  intestines. 
The  uterus  itself,  as  the  above-mentioned  case  well  illustrates, 
forms  in  many  instances  only  a  comparatively  small  portion  of  the 
large  external  tumor  which  often  exists  in  cases  of  complete  prgci- 
dentia.  The  susceptibilities  of  the  organ  seem  indeed  to  be  much 
diminished,  and  with  them  its  disposition  to  hypertrophy  when  it 
has  come  to  reside  habitually  out  of  the  pelvic  cavity.  Sometimes, 
indeed,  as  in  the  case  just  referred  to,  the  womb  appears  actually 
diminished  (it  measured  in  that  instance  less  than  two  inches  from 
its  orifice  to  its  fundus),  and  I  believe  that  the  difficulty  which 
may  be  experienced  in  the  replacement  of  long-standing  i)roci- 
dentia  of  the  uterus  seldom  if  ever  arises  from  the  size  of  that 
organ.  The  bulk  of  the  tumor,  and  the  difficulty  of  its  replace- 
ment, depend  chiefly  upon  two  causes.  Of  these  the  one  consists 
in  the  enormous  hypertrophy  which  the  vaginal  walls  undergo. 
Not  only  does  their  mucous  membrane  lose  its  ordinary  character, 
and  become  covered  by  a  layer  of  cuticle  like  that  of  the  skin,  to 
protect  it  from  the  various  sources  of  irritation  to  which  it  now 
becomes  exposed,  but  the  walls  themselves  attain  a  thickness  of 
as  much  as  half  an  inch,  and  present  a  dense  muscular  structure. 
The  other  cause  of  the  bulk  of  the  tumor,  and  of  the  difficulty  of 
replacing  it,  arises  from  the  presence  of  the  intestines  in  the  sac, 
which  seldom  reside  there  long  without  inflammation  of  their 
peritoneal  covering  being  set  up;  not^of  so  acute  a  character,  in- 
deed, as  to  produce  formidable  sjmiptoms,  nor  even  as  always  to 
cail  for  treatment,  but  matting  their  difl'erent  coils  to  each  other, 
and  tying  them  firmly  to  the  interior  of  the  sac.  This  latter  cause 
of  difficulty  in  the  attempt  to  return  a  procident  uterus  must  not 
be  lost  sight  of,  even  though  no  intestines  should  seem  to  have 
descended  into  the  external  tumor  itself,  for  the  same  slow  form 
of  peritoneal  inflammation  may  glue  them  to  each  other  and  to 


IN     PROCIDENTIA     OF    THE     UTERUS.  133 

the  walls  of  the  pelvic  cavity,  and  thus  efFectnally  close  np  the 
walls  against  all  endeavors  to  replace  the  womb. 

In  the  eases  which  we  have  hitherto  studied,  though  tlie  point  of 
departure  of  the  whole  evil  consisted  in  a  weakening  of  the  vagina, 
yet  that  step  once  taken,  the  prolapse  of  the  womb  miglit  be  re- 
garded as  a  primary  occurrence,  the  organ  in  its  descent  dragging 
down  the  vagina  with  it.  There  are,  however,  other  cases  in 
which  the  displacement  of  the  womb  is  entirely  a  secondary  atci- 
dcTit,  following  on  a  giving  way  of  the  anterior  or  posterior  vaginal 
wall,  which  becomes  prolapsed,  and  in  its  prolapsus  draws  down 
the  uterus.  It  is  thus,  for  instance,  that  prolapsus  uteri  is  some- 
times brought  about  in  cases  of  ascites,  the  pressure  of  the  fluid 
gradually  distending  the  recto-vaginal  pouch,  till  it  may  even  cause 
the  posterior  wall  of  the  vagina  to  protrude  externally.  A  similar 
effect  is  sometimes  produced  in  cases  of  long-continued  constipa- 
tion, in  which  the  accumulation  of  faeces  in  the  rectum  l)y  degrees 
distends  the  intestine  into  a  pouch  which  projects  into  the  vagina, 
while  still  more  frequently  the  anterior  vaginal  wall  gives  way 
from  the  retention  of  urine  in  the  bladder,  and  thus  produces  in 
the  course  of  time  a  similar  descent  of  the  womb.  There  is,  be- 
sides, a  form  of  vaginal  prolapse  due  apparently  to  hypertro{)hy 
of  the  walls  of  tlie  canal,  in  which  the  position  of  the  adjacent 
viscera  is  not  altered,  tliough  the  os  uteri  is  not  infrequently 
found  lower  down  than  natural,  owing  to  the  prolajjsed  vagina 
dragging  at  the  cervix,  and  exciting  the  part  to  overgrowth  by  the 
constant  irritation  which  it  thus  maintains. 

Strictly  speaking,  these  different  affections  of  the  vagina  should 
be  reserved  for  our  consideration  by  and  by;  but  there  is  such  a 
general  similarity  between  their  symptoms  and  those  of  prolapsus 
of  the  uterus,  and  so  close  a  correspondence  between  thej)rinci- 
ples  of  treatment  applicable  to  them,  that  we  may  very  well  sacri- 
fice systematic  arrangement  to  practical  convenience. 

First,  now,  with  reference  to  prolapsvs  of  the  vagina  unaccom- 
panied by  misplacement  of  the  other  pelvic  organs,  I  have  already 
mentioned  that  it  seems  to  depend  in  the  first  instance  on  a  sort 
of  hypertrophy,  as  the  result  of  which  it  cannot  well  be  contained 
within  its  proper  limits,  but  a  fold  of  it  comes  to  protrude  beyond 
the  external  parts.  Such  an  hypertrophy  of  the  vagina  takes  place 
during  pregnancy,  for  not  only  does  the  womb  groAv  to  keep  pace 
with  the  development  of  the  fnetus,  but  the  vagina  grows  too; 
longitudinally,  to  allow  the  womb  to  ascend  high  u\)  above  the 
pelvic  l)rim;  transversely,  to  afi(>rd  space  for  the  ])assage  of  the 
child  in  labor,  room  for  which  could  not  be  obtained  by  any  mere 
stretching  of  a  membranous  canal.  When  labor  is  over,  the 
vagina,  in  common  with  the  uterus,  ought  to  diminish  in  size  by 
a  removal  of  much  of  its  old  material.  Sometimes,  however,  just 
as  we  have  already  seen  in  the  case  of  the  uterus,  this  involution 
is  imi»erfect,  and  the  vagina  then  remains  longer  and  wider,  and 
with  its  walls  thicker  than  they  should  be,  and  as  soon  as  the  pa- 
tient begins  to  move  about  again,  or  to   niake  any  exertion,  a 


134  PROLAPSE     OF    VAGINA. 

portion,  often  the  whole  cylinder  of  the  loM^er  part  of  the  vagina, 
hangs  down  outwardly,  an  accident  all  the  more  likely  to  take 
place  if  the  perineum  has  been  injured,  or  if  the  levator  ani  and 
the  tiiscia  at  the  pelvic  floor  have  lost,  as  they  are  wont  to  do,  much 
of  their  power  of  resistance  by  frequent  childbearing.  Why  it 
is  that  sometimes  the  vagina  continues  thus  hypertrophied  while 
the  involution  of  the  uterus  has  gone  on  properly,  I  cannot  say, 
though  of  the  fact  itself  there  can  be  no  doubt ;  for  one  meets 
occasionally  with  cases  in  which  the  uterus,  still  suspended  by  its 
ligaments  and  by  the  folds  of  peritoneum,  is  little  if  at  all  lower 
than  natural,  and  little  if  at  all  altered  in  size,  while  the  vagina  is 
so  wide  as  readily  to  admit  several  fingers,  and  its  folds  hang 
down  loosely  to  or  even  beyond  the  orifice  of  the  vulva. 

Although  this  prolapsus  of  the  vagina  is  usually  a  primary  af- 
fection, and  attributable  to  the  consequences  of  pregnancy  and 
childbearing,  yet  this  is  not  so  invariably.  The  prolapse  of  the 
vagina  appears  to  be  in  some  instances  consecutive  to  descent  of 
the  womb,^  but  the  affection  being  neglected,  the  tissue  of  the 
protruding  portion  of  vagina  may  become  hj^pertrophied,  and  the 
ailment  which  was  secondary  in  importance,  may  by  degrees  be- 
come of  greater  moment  than  the  misplacement  of  the  womb,  and 
morf"  difficult  to  remedy. 

Though  not  quite  constant,  yet  the  exceptions  are  but  few  to  the 
rule  that  considerable  or  long-standing  prolapsus  of  the  vagina  will 
produce  hypertrophy  of  the  cervix  of  the  uterus;  not  of  that  por- 
tion only  which  projects  into  the  vagina  or  portio  vaginalis,  as  it  is 
termed  by  continental  writers,  but  of  the  whole  uterine  neck,  of 
which  a  specimen  (Series  xxxii,  30)  in  the  Museum  of  St.  Bartholo- 
mew's Hospital,  afibrds  a  striking  illustration.  Even  more  remark- 
able instances  of  this  kind  are  on  record,  one  of  the  first  of  which 
was  described  by  Morgagni,^  and  attention  was  drawn  some  few 
years  afterwards  to  their  practical  bearings  by  Levret.^  He  clearly 
pointed  out  the  differences  between  those  cases  in  which  the  ap- 
proach of  the  OS  uteri  to  the  vulva  is  mainly  due  to  overgrowth 
of  the  cervix,  and  the  others  in  which  it  is  entirely  the  result  of 
the  descent  of  the  womb.  His  remarks,  however,  were  lost  sight 
of,  and  it  was  with  no  previous  knowledge  of  them  that  Virchow,* 

'  Eemarks  made  by  Professor  Kiwisch,  Klinische  Vortrage,  vol.  ii,  2d  edition, 
1852,  p.  413. 

2  Morgagni,  De  Sedihus  et  Can.sis  Morborum,  folio,  Venetiis,  1761,  2d  vol.,  Epist. 
45,  Art.  11,  p.  204.  Morgagni  regarded  the  hypertrophy  of  the  cervix  in  this  case 
as  consequent  on  the  prolapse  and  hypertrophy  of  the  vagina.  "Evidens  est,  vagina9 
adeo  crassae  pondere  deorsum  tractiim  fuisse  uterum,  cujus  fundus  aliquanto  inferior 
fuisset,  nisi  cervix  jam  inde  ab  initio,  ut  puto,  ea  esset  laxitate,  ut  so  prse  cseteris 
distrahi,  distendique  in  raram  istara  longitudinem  sineret. " 

3  Journnl  de  Medecine,  Chiru?-gie,  etc.,  par  M.  A.  Roux,  vol.  xl,  Oct.  1773,  p.  352, 
"  Sur  un  allongement  considerable  qui  survient  quelquefois  au  col  de  la  Matrice." 
Attention  was  called  to  this  state,  with  a  completeness  of  detail  which  leaves  but 
little  to  be  added,  by  Prof.  Stolz  of  Strasbourg,  in  Journnl  Hebdomadaire,  vol.  vi, 
June  10,  1859,  p.  356,  where,  however,  by  a  misprint,  the  date  of  Levret's  paper  is 
given  1775  instead  of  1773. 

^  Yirchow,  in  Verhandl.  der  Gesellschaftf.  Geburtsh.  in  Berlin,  vol.  ii,  1847,  p.  205. 


PROLAPSE    OF    BLADDER.  135 

some  few  years  since,  described  this  occurrence  as  a  peculiar  form 
of  prolapse,  under  the  name  of  prolapsus  uteri  ivithout  descent  of  the 
fiuiduH.  Still  more  recently  the  subject  has  been  brought  into 
undue  prominence  by  the  assertion  of  M.  Huguier,^  that  prolapsus 
of  the  uterus  is  a  condition  that  scarcely  ever  exists;  but  that 
cervical  hypertrophy  lias  been  almost  invariably  mistaken  for  it, 
and  that  consequently  not  the  supi)ort  of  the  womb,  but  the  re- 
moval of  the  elongated  cervix,  is  the  ])roceeding  to  which  one 
ought  to  have  recourse.  Like  most  extreme  statements  tliis  of 
M,  Iluguier,  is  contradicted  by  general  observation.^  Still  it  is 
well  for  you  always  to  bear  in  mind,  not  only  that  hypertroph}^  of 
the  uterus  tends  to  favor  its  prolapse,  and  that  the  prolapsed  uterus 
tends  to  enlarge  still  more,  but  also  that  long-standing  prola])Sus 
of  the  vagina  is  almost  alwaj'S  associated  with  a  condition  of  the 
cervix  uteri  which  closely  simulates  ordinary  prolapsus,  but  which, 
as  you  will  hereafter  see,  must  be  clearly  distinguished  from  it, 
since  those  attempts  at  mechanically  rectifying  the  supposed  mal- 
position which  would  be  of  service  in  true  descent  of  the  womb, 
must  here  be  useless,  and  sometimes  may  even  aggravate  the  suf- 
ferings of  the  patient. 

Of  much  more  frequent  occurrence  are  those  cases  in  which  the 
prolapse  of  the  vaginal  wall  is  partial,  involving  its  anterior  or 
posterior  part  only,  and  deriving,  in  the  great  ma,jority  of  ins  "'.^ices, 
its  chief  importance  from  the  altered  position  of  theadjacent  organs, 
which  descend  into  the  pouch  thus  formed,  and  constitute  what 
have  been  termed  by  many  writers  vaginal  rectocele  and  vaginal 
cystocele. 

In  those  cases  where  the  anterior  vaginal  wall  gives  way,  forming 
a  pouch  into  which  more  or  less  of  the  bladder  descends,  it  is  not 
easy  to  sa}^  what  is  the  first  step  in  the  occurrence  ;  whether  the 
vagina  draws  down  the  bladder  with  it,  or  whether  the  distended 
bladder  ])uslies  before  it  the  vaginal  wall.  It  is  an  accident,  how- 
ever, which  in  the  unmarried  is  even  more  rare  than  prolapse  of 
the  womb,  and  its  occurrence  is  traced  back,  in  by  far  the  majority 
of  those  who  suffer  from  it,  to  a  miscarriage  or  labor;  to  a  time, 
in  short,  at  which  all  the  parts  were  loose,  and  had  lost  the  power 
of  resistance,  while  the  vagina  as  well  as  the  uterus  was  liyper- 
troi)hied,  ;ind  had  to  undergo  that  process  of  ]iost-puerperal  involu- 
tion to  which  I  have  had  such  frequent  occasion  to  refer.  Some- 
times, indeed,  though  rarely,  the  patient  gives  a  history  of  the 
sudden  formation  of  a  swelling  at  the  anterior  part  of  the  vagina 
during  some  unwonted  exertion,  just  as  the  womb  itself  occasion- 

1  Tn  a  memoir  road  bofore  tho.  Academy  of  Medicine  on  "Marcli  8,  ISHO,  and  |)iil)- 
lished  in  vol.  xxiii  of  the  Memoir es  de  V Academic — "  Siir  les  aiiongements  iiypi-r- 
tro])liiques  dn  col  do  rut^nis." 

*  See  especially  the  discussions  to  which  this  paper  p;ave  rise,  as  reported  in  the 
Bulletin  de  VAcndemie,  vol.  xxiv,  p.  072,  727,  771.  704;  a  pa]);'r  by  Scan^oni,  at 
p.  820  of  the  4th  voliiine  of  his  lieiJn'if/e  zur  Oehirtslmmle  ;  Aran.  <>p.  ril.,  p.  10.14; 
McClintock  on  Disrnsex  of  Womrn,  8vo.,  Dublin,  ISC.:?,  p.  ')S :  and  Mayer,  Klinisc/ie 
Mitthedumjen  aus  dem  Gebiiie  drr  Oi/nii/.n/ni/ie,  4to.,  1  Heft,  IJerlin,  18G1,  p.  33. 


136  PROLAPSE     or    BLADDER 

ally  becomes  prolapsed  in  similar  circumstances;  while  it  is  easy 
to  understand  bow  a  comparatively  small  prolapse  may  be  con- 
verted into  a  large  one  during  some  violent  effort  when  the  bladder 
is  full,  and  consequently  exposed  to  all  the  force  of  the  diaphragm 
and  abdominal  muscles  pressing  downwards. 

The  union'  is  so  much  more  intimate  between  the  anterior 
vaginal  wall  and  the  bladder,  than  between  the  posterior  vaginal 
wall  and  the  rectum,  that  we  scarcely  ever  find  the  vagina  alone 
becoming  prolapsed,  and  dragging  itself  away  from  the  bladder  in 
the  same  manner  as,  in  prolapse  of  its  posterior  wall,  it  often  be- 
comes separated  from  the  rectum.  Further,  that  part  of  tlie  blad- 
der which  adheres  to  the  vagina  includes  the  orifice  of  both  ureters 
and  the  whole  of  the  trigone,  extending,  indeed,  somewhat  beyond 
its  limits  on  either  side,  so  that  the  urine,  as  soon  as  secreted,  col- 
lects in  tliis  situation,  and  tends  constantly  to  distend  it  into  a 
pouch,  whose  dimensions  increase  all  the  more  rapidly  since  its 
enlargement  is  not  opposed  by  the  weight  of  the  superincumbent 
intestines  and  the  antagonism  of  the  abdominal  muscles,  both  of 
which  have  to  be  overcome  as  the  distended  bladder  rises  out  of 
the  pelvic  cavity. 

A  slight  pouch  then  is  first  formed  in  the  anterior  vaginal  wall, 
scarcely  perceptible  when  the  bladder  is  completely  empty,  but 
tense  and  elastic  when  filled  with  urine,  though  admitting  even 
then  of  being  partially  or  completely  removed  by  firm  pressure 
upon  it,  and  disappearing  altogether  if.  while  this  pressure  is  being 
made,  a  catheter  is  introduced  into  the  bladder.  In  the  course  of 
time  the  small  tumor,  whose  anterior  border  was  felt  a  little  be- 
hind the  symphysis  pubis,  enlarges,  now  and  then  forming  a  kind 
of  diverticulum,^  with  a  narrow  neck  and  long  pedicle,  but  oftener 
producing  a  globular  swelling,  which  fills  up  the  canal  of  the 
vagina,  and  projects  more  or  less  bej'ond  the  external  parts,  when 
it  becomes  covered  by  the  same  investment  of  ordinary  skin  as 
clothes  the  tumor  in  prolapsus  of  the  uterus  or  vagina.  The  weak- 
ening and  giving  way  of  the  anterior  vaginal  wall,  however,  sel- 
dom attain  any  very  great  degree  without  producing  likewise  some 
prolapse  of  the  uterus,  though  the  extent  of  this  is  by  no  means 
constant.  Whenever  the  uterus  does  not  readily  yield  to  the 
traction  made  on  it  by  the  prolapsed  bladder,  the  anterior  lip  of 
the  organ  becomes  hypertrophied,  and  projects  far  beyond  the 
posterior;  in  a  similar  W'ay,  though  not  to  tlje  same  degree,  as  w^e 
.have  already  observed  to  be  the  case  with  the  whole  of  the  neck 
of  the  womb,  in  cases  of  prolapse  of  the  w%ole  circumference  of 
the  hypertrophied  vagina. 

The  dragging  of  the  prolapsed  portion  of  the  bladder  upon  the 

1  The  exact  relations  of  these  parts  are  nowhere  so  well  described  as  by  Dubois, 
Traite  de  V Art  des  Accouchemens,  pp.  190-199,  and  pp.  234-243;  nor  so  well  de- 
lineated as  \>y  Kohlrausch,  Z«<r^H«fo>me,  Sfe.,der  Beckenorgane,  4to.,  Leipsic,  1854. 

2  As  in  a  case  described  by  Madame  Lachapelle,  Pratique  des  Accouchemens,  vol. 
iii,  p.  387,  in  which  the  prolapsed  bladder  was  driven  down  in  this  form  before  the 
fcetal  head,  and  beyond  the  external  parts. 


AND    RECTUM.  137 

neck  of  the  organ  naturally  interferes  with  the  functions  of  the 
part,  and  produces  frequent  desire  to  pass  water,  as  well  as  in  many 
instances  inability  to  retain  it.  Another  eviP  which  occasionally 
results  from  it  (l)ut  wliich  I  have  failed  to  observe  in  the  few  cases 
where  I  have  been  present  at  a  posf-mortetn  examination  of  women 
who  suffered  from  prolapsus  of  the  bladder,  probably  from  want  of 
directing  special  attention  to  the  point),  consists  in  a  degeneration 
of  the  kidneys  themselves.  The  ureters  being  not  only  drawn  down 
and  stretched,  but  also  in  some  instances  even  pressed  ui)on  as  the 
pouch  of  prolapsed  bladder  projects  under  the  symphysis  pubis,  the 
urine  with  difficulty  tlows  along  them  ;  and  both  they  and  the  pelvis 
of  the  kidneys  themselves  become  dilated,  with  a  corresponding 
atrophy  of  the  secreting  substance  of  these  organs. 

Prolapse  of  the  posterior  vaginal  wall  is  in  its  slighter  degrees  of 
more  common  occurrence  than  prolapse  of  the  anterior,  and  when 
the  perineum  has  been  torn  in  labor,  scarcely  ever  fails  to  take 
place.  It  does  not,  however,  constantly  bring  with  it  prolapse  of 
the  rectum  in  the  same  manner  as  the  giving  way  of  the  anterior 
vaginal  wall  is  constantly  associated  with  prolapse  of  the  bladder, 
since  the  loose  cellular  tissue  which  connects  them  allows  of  a 
tolerably  ready  separation  between  the  two  canals,  and  the  rectum 
ma}'  still  retain  its  natural  situation.  If,  liowever,  the  laceration 
of  the  perineum  has  been  considerable,  or  if,  independent  even  of 
any  such  condition,  the  bowels  have  been  habitually  allowed  to  be 
constipated,  the  lower  part  of  the  rectum  bulges  out  into  acuhde- 
sac,  in  which  fecal  masses  become  retained  and  indurated,  causing, 
in  addition  to  the  ordinary  annoyances  of  prolapsus,  much  discom- 
fort, sometimes  even  much  sufiering,  in  the  act  of  defecation.  It 
is  to  the  influence  of  constipation  in  producing  this  ailment  that 
must  be  attributed  the  comparative  frequency  with  which  it  is  ob- 
served, independent  of  pregnancy  and  childbearing ;  and  its  im- 
portance arises  in  great  measure  from  its  aggravating  that  state  of 
the  bowels  to  which  its  original  occurrence  was  mainly  due. 

1  Ileferred  to,  both  by  Kiwis-ch,  lib.  cit,  vol.  ii,  p.  422;  and  by  Vircliow,  loc. 
cit,  p.  209  ;  by  the  latter  of  whom  it  is  more  fully  described. 


138  SYMPTOMS    OF    PROLAPSUS    UTERI. 


^  LECTURE    X. 

MISPLACEMENTS  OF   THE  UTERUS. 

Prolapsus  Uteri.  Sj^mptoms  of  its  first  and  second  stages;  pain,  its  causes  and 
character,  disorder  of  uterine  functions,  and  of  general  health  Symptoms  of 
third  stage;  influence  of  misplacement  on  adjacent  organs;  difficulty  of  return 
of  long-standing  procidentia.  Peculiar  symptoms  of  prolapsus  of  bladder  and 
rectum  described  and  explained. 

Treatment  of  Prolapsus  varies  according  to  its  cause  and  degree.  Cases  requiring 
or  not  requiring  mechanical  support,  distinguished;  pessaries,  their  uses  and 
varieties;  external  supports  and  bandages. 

Management  of  Procidentia;  cautions  as  to  replacement  of  uterus;  treatment  of 
ulcerations  of  its  surface.  Operations  for  its  permanent  cure  considered.  Irre- 
ducible procidentia;   extirpation  of  womb. 

After  the  stud}-  of  the  manner  in  which  some  forms  of  mis- 
placement of  the  uterus  and  parts  therewith  connected  are  pro- 
duced, we  come  next  to  inquire  into  the  symptoms  to  which  those 
misplacements  give  rise.  The  symptoms  depend  partly  on  the 
changes  in  the  relations  of  the  various  organs  produced  b}'  their 
altered  position,  or  by  the  altered  position  of  the  womb  itself; 
partly  on  direct  dii^turbance  of  the  uterine  functions,  and  partly, 
too,  on  the  sympathy  of  distinct  organs  with  the  ailments  of  the 
womb  itself.  I^one  of  these  symptoms,  however,  are  constantly 
proportionate  in  severity  to  the  degree  of  misplacement,  so  that 
one  woman  will  sutler  most  acutely  from  comparative  slight  descent 
of  the  womb,  while  another  will  pursue  laborious  avocations,  ap- 
parently little  distressed  by  a  prolapsus  so  considerable  that  the 
uterus  is  with  difHculty  retained  within  the  canal  of  the  vagina. 

As  a  general  rule,  the  patient  suffers  most  in  those  cases  in 
which  the  occurrence  of  prolapsus  has  been  somewhat  sudden,  and 
in  w^hich  it  does  not  succeed  to  previous  delivery  or  miscarriage. 
The  reasons  for  this  are  obvious  enough  ;  the  dragging  at  the 
uterine  ligaments  and  duplicatures  of  peritoneum  must  be  much 
more  painful  when  they  have  been  suddenly  stretched,  than  when, 
already  loose  and  yielding,  they  give  way  under  the  weight  of  the 
uterus  which  they  are  prematurely  called  upon  to  bear.  Hence  it 
is  that  comparativel}^  slight  prolapsus  in  the  unmarried  is  often 
attended  by  far  more  distress  than  a  much  greater  amount  of  dis- 
placement in  women  who  have  given  birth  to  children,  and  that 
the  degree  of  suffering  which  is  sometimes  experienced  after  a 
night's  dancing,  or  a  fatiguing  ride  on  horseback,  seems  to  point 
to  an  ailment  far  more  serious  than  slight  descent  of  the  womb. 

Women  designate  the  peculiar  pain  which  they  experience  in 
cases  of  prolapsus  uteri  by  the  expressive  terifi,  "bearing  down ; " 
a  sensation  as  though  the  pelvic  viscera  were  about  to  fall  out ; 
and  to  this  is  often  added  on  very  slight  exertion,  such  as  in  walk- 
ing, in  lifting  anything,  or  on  altering  the  posture,  a  sharp  pain, 
due  to  a  momentary  increase  of  tension  of  the  uterine  ligaments, 


SYMPTOMS    OF    PROLAPSUS    UTERI.  139 

which  compels  the  person  to  stand  still,  and  often  to  bend  slightly 
forwiirds,  so  as  to  remove  as  far  as  possi])le  all  pressure  from  above, 
and  tlins  to  await  the  cessation  of  the  i)ain.  The  effort  at  defeca- 
tion is  often  extremely  painful,  from  tlie  very  circumstance  that 
it  puts  all  those  ligaments  upon  the  stretch,  while,  when  the 
womb  has  descended  so  far  that  its  cervix  habitually  rests  upon 
the  floor  of  the  vagina,  there  is  frequently  superadded  a  sense  of 
desire  to  empty  the  rectum,  a  sort  of  tenesmus  which  is  verj-  dis- 
tressing. The  uterus,  too,  becomes  now  exposed  to  shocks  from 
various  external  causes  from  wliich  it  was  before  defended  ;  and 
sitting  on  a  hard  seat,  or  placing  herself  in  any  posture  in  which 
the  perineum  is  pressed  on,  causes  the  patient  extreme  pain,  so 
that  she  is  compelled  to  study  her  attitudes,  and  carefully  to  adjust 
her  position.  With  these  discomforts  there  is  almost  always  asso- 
ciated more  or  less  of  that  pain  in  the  back  which  is  the  nearly 
constant  attendant  upon  uterine  ailments  of  every  kind;  and  in 
some  instances  there  is  also  an  extreme  degree  of  tenderness  or 
sensitiveness  in  the  hypogastric  region,  which  is  not  aggravated 
by  slight  pressure  on  the  surface,  or  by  gentle  friction  over  it,  but 
on  the  contrary  is  often  much  relieved  by  it.  This  abdominal  pain 
is  no  more  special  to  prolapsus  than  is  the  lumbar  pain,  but  both 
seem  due  to  the  radiation  of  painful  sensations  from  the  uterus 
itself,  along  the  different  nervous  branches  and  twigs  with  which 
it  is  either  directly  or  indirectly  connectly;  and  hence  we  find  it 
in  many  cases  of  uterine  cancer,  as  well  as  in  dysmenorrho^a,  and 
in  very  many  other  chronic  ailments  of  the  uterus.  Another  very 
distressing  sensation  often  experienced  quite  in  the  early  stage  of 
uterine  prolapsus,  and  before  there  is  any  interference  with  the 
position  of  the  bladder,  is  a  very  frequent  desire  to  pass  water, 
which  the  patient  is  compelled  to  do  every  half  hour,  though  with 
very  little  relief.  In  unmarried  women,  when  the  uterus  has 
descended  so  as  to  lie  in  the  axis  of  the  pelvic  outlet,  there  is 
besides  much  distress  produced  by  the  os  uteri  pressing  against 
the  hymen ;  but  all  of  these  discomforts  are  mitigated,  many  of 
them  cease  altogether  when  the  patient  lies  down. 

Pain,  however,  is  not  the  only  symptom  of  prolapsus  of  the 
womb.  ■  The  organ  thus  misplaced  is  irritated,  and  leucorrhoeal 
discharges  are  an  almost  invariable  attendant  upon  the  ailment, 
while,  from  the  same  cause,  the  menstrual  flux  becomes  more  pro- 
fuse, lasts  longer,  or  returns  more  frequently  than  natural.  The 
blood  flows  back  from  the  misplaced  womb  with  more  than  ordi- 
nary difhculty,  a  state  of  habitual  congestion  is  maintained,  which 
in  some  instances  relieves  itself  from  time  to  time  by  profuse 
losses  of  blood,  though  in  spite  of  them  the  irritated  congested 
organ  tends  to  increase  in  size,  and  the  womb,  thus  larger  and 
heavier  than  natural,  becomes  less  and  less  likely  to  resume  its 
natural  situation. 

The  disorders  of  the  general  health  that  accompany  prolapsus 
of  the  womb  have  nothing  in  them  that  is  characteristic,  but  con- 
sist of  that  class  of  symptoms  which  attend  upon  so  many  uterine 


140  SYMPTOMS    OF 

ailments,  and  among  whicli  dyspeptic  disorders  have  a  very  large 
share,  owing  to  the  peculiar  sympathy  that  subsists  between  the 
stomach  and  the  womb.  Constipation  of  the  bowels  may,  however, 
be  mentioned  as  an  almost  constant  attendant  upon  prolapsus,  due 
in  part  to  the  distress  which  in  the  early  periods  of  the  affection 
accompanies  the  effort  at  defecation  ;  in  part  also  to  the  mechani- 
cal impediment  which  the  pressure  of  the  cervix  uteri  on  the  rec- 
tum frequently  offers  to  the  passage  of  the  fseces. 

In  the  u})per  classes  of  society,  the  symptoms  of  prolapsus  are 
almost  invariably  met  by  approj)riate  treatment  in  the  early  stages 
of  the  affection,  so  that  in  them  it  seldom  passes  the  first  or  second 
degree  of  misplacement.  There  may,  however,  be  exceptions  to 
this  rule,  in  cases  where  the  perineum  bas  been  extensively  torn 
and  the  vagina  has  consequently  been  very  much  and  permanently 
weakened.  The  atrophy  of  advancing  age  being  equally  inci- 
dental to  all,  the  uterus  may  even  in  the  wealth}^  come  down  so 
low  as  to  protrude  partially  beyond  the  external  parts.  Xow  and 
then,  too,  even  in  young  w^omen,  tlie  perineum  after  childbirth 
seems  so  completely  to  lose  its  resiliency  as  to  afford  little  or  no 
support  to  the  vagina.  A  small  knuckle  of  the  posterior  vaginal 
wall  soon  becomes  prolapsed,  so  as  to  project  between  though  not 
beyond,  the  labia  ;  it  here  becomes  irritated ;  and  irritated,  it  soon 
becomes  hypertrophied.  The  edge  of  the  yielding  perineum  is 
dragged  down  by  the  vagina,  or  if  an  examination  be  made,  is 
easily  carried  before  the  fingers,  and  seeming  thus  to  constitute  a 
part  of  the  vaginal  wall,  the  sensation  of  the  perineum  having 
been  nearly  destroyed,  is  most  deceptive;  and  sometimes  the  eye 
alone  can  determine  whether  this  is  so  or  not.  Now,  in  this  case 
the  vaginal  support  of  the  uterus  being  completely  lost,  though 
the  mischief  is  not  irreparable,  as  it  must  be  when  the  perineum 
is  torn,  external  prolapse  of  the  uterus  may  take  place. 

The  sudden  occurrence  of  external  prolapse,  or  procidentia, 
when  it  happens  during  some  violent  exertion,  or  when  it  takes 
place  all  at  once  during  some  change  of  posture  a  short  time  after 
parturition,  or  in  the  effort  at  defecation,  is  attended  by  much 
local  distress,  and  much  constitutional  disturbance.  In  by  far  the 
majority  of  cases,  however,  the  womb  becomes  procident  ordy  very 
gradually;  at  first  but  a  small  part  of  the  organ  protruding,  and 
that  only  occasionally,  and  then  more  of  it  coming  down,  and  for 
a  longer  time,  till  at  last  the  whole  womb  lies  usually,  or  con- 
stantly, beyond  the  external  parts.  With  tliis  change  of  position 
of  the  organ  there  is  a  change  of  symptoms;  often,  indeed,  a 
marked  remission  of  some  of  those  which  were  the  most  distress- 
ing; for  the  sensibilities  of  the  womb  appear  to  be  greatly  blunted 
when  once  it  becomes  an  external  organ,  and  injuries  and  interfer- 
ences which  it  could  not  bear  while  in  its  natural  situation  seem 
to  be  of  but  small  importance  when  it  has  left  the  pelvic  cavity. 

The  alleviation  of  the  patient's  symptoms,  however,  owing  to 
the  cessation  of  the  vaginal  leucorrhoea,  and  the  gradual  ])lnnting 
of  the  uterine  sensibilities,  is  generally  more  than  counterbalanced 


PROLAPSUS     UTERI.  141 

by  the  supervention  of  suffering  from  other  sources.  With  the 
increase  of  the  procidentia  of  the  uterus,  the  position  of  the  other 
pelvic  organs  becomes  more  and  more  disturbed ;  the  bhidder  is 
drawn  down  into  the  pouch  in  front,  and  the  natural  relations  of 
the  urethra  are  often  so  altered  that  the  canal  runs  perpendicularly 
downwards,  instead  of  in  a  horizontal  direction.  This  misplace- 
ment necessarily  brings  with  it  much  difficulty  in  emptying 
the  bladder,  while  accompanying  it  there  is  generally  a  fre- 
quent desire  to  void  the  urine,  and  by  these  two  symptoms  the 
patient's  life  is  rendered  miserable.  In  a  similar  manner,  though 
not  so  invariably,  the  rectum  is  drawn  down  behind,  and  difficult 
defecation  is  thus  superadded  to  the  other  symj^toms.  Nor  is  this 
all,  but  the  descent  of  the  small  intestines  into  the  pelvic  cavity  to 
occupy  the  space  which  the  uterus  and  adjacent  viscera  have  left 
vacant  there,  disturbs  their  proper  functions,  and  gives  rise  to 
various  sensations  of  pain  and  discomfort  in  the  abdomen,  and  to 
these  is  not  infrequently  added  the  distress  from  inflammation  of 
the  peritoneum,  a  chronic  form  of  which  seldom  fails  to  be  set  up. 

The  external  tumor  is  itself  the  source  of  much  distress.  In 
spite  of  the  thickening  of  its  tegument,  the  irritation  produced  by 
exposure  to  the  air,  and  by  all  the  forms  of  external  injury  from 
which  it  is  impossible  to  shield  it,  as  well  as  by  the  passage  of  the 
urine  and  fteces,  seldom  fails  to  produce  iilceration  of  its  surface. 
This  ulceration  generally  occurs  m  large  patches  upon  the  most 
exposed  parts;  as,  for  instance,  at  the  sides,  where  the  tumor  is 
exposed  to  friction  by  the  thigh;  below,  where  it  is  rubbed  when 
the  patient  sits  or  lies,  and  at  the  upper  part,  where  it  is  apt  to 
be  made  sore  by  the  passage  of  the  urine.  The  ulcers  are  seldom 
deep,  but  are  usually  irregular,  with  raised  edges  and  an  indolent 
surface,  and  are  very  indisposed  to  heal.  The  os  uteri,  too,  from 
its  position  at  the  lower  part  of  the  tumor,  and  its  consequent  ex- 
posure to  irritation,  as  well  as  from  the  delicacy  of  the  membrane 
in  this  situation,  is  almost  always  the  seat  of  an  ulcer  or  excoria- 
tion. This  ulceration  is  often  of  considerable  extent;'  not  simply 
from  the  circumstance  that  the  lips  of  the  os,  partaking  of  the 
general  hypertroiohy  of  the  w^omb,  present  a  large  surface,  but  also 
because  the  continual  dragging  of  the  inverted  vagina  tends  to 
draw  the  lips  of  the  uterus  upwards  and  apart  from  each  other, 
and  thus  produces  a  ver}'  considerable  eversion  of  the  mucous 
membrane  of  the  cervical  canal,  which  soon  becomes  excoriated. 
The  replacement  of  the  uterus  restores  the  parts  to  their  natural 
relations,  and  the  large  external  ulceration  passes  almost  out  of 
sight  into  the  canal  of  the  cervix. 

The  existence  of  prolapsus  uteri,  though  no  bar  to  conception, 
often  renders  pregnancy  a  period  of  very  considerable  suil'ering. 
The  slighter  degrees  of  descent  of  the  womb,  indeed,  are  often 

1  This  fact,  of  the  correctness  of  which  any  one  can  readilj'  satisfy  himself,  was, 
to  the  best  of  my  knowledge,  first  noticed  by  Scanzoni,  in  a  note  ut  page  178  of 
the  4th  edition  of  vol.  i  of  Kiwisch,  Kdniscke  Vorirdge. 


142  SYMPTOMS    OF 

cured  by  pregnancy,  since  the  uterus  as  it  enlarges  gradually  as- 
cends in  the  pelvis  ;  and  the  temporary  relief  thus  afforded  may 
be  rendered  permanent  by  care  during  gestation,  and  a  long  ob- 
servance of  the  recumbent  posture  after  delivery.  Wlien  the  mis- 
placement, however,  is  considerable,  and  especially  when  the 
uterus  has  already  been  partially  procident,  the  effect  of  the  en- 
largement of  the  womb  is  to  make  it  descend  still  lower,  so  that 
a  consideracle  portion  of  its  lower  segment,  as  well  as  its  greatly 
enlarged  cervix,  protrude  permanently  during  a  great  part  or  the 
whole  of  pregnancy.  All  the  symptoms  to  which  prolapsus  ordi- 
narily gives  rise  are  experienced  in  these  cases  in  an  aggravated 
degree,  and  miscarriage  not  infrequently  takes  place,  partly  owing 
to  the  disturbance  inseparable  from  the  misplacement  of  the  womb, 
partly  owing  to  the  want  of  space  in  the  pelvis  for  the  further  en- 
largement of  the  organ,  which  is  unable  to  rise  as  it  ought  to  do 
into  the  abdominal  cavity.  In  some  few  instances,  however, 
pregnancy  runs  its  course  undisturbed,  in  spite  of  a  great  degree 
of  prolapsus;  and  cases  are  on  record  in  which  the  uterus  has 
descended  furthef  and  further  till  a  great  portion  of  it  hung  down 
between  the  thighs  ;  but  the  development  of  the  foetus  has,  never- 
theless, gone  on  in  this  unnatural  position ;  and  others,  still  stranger, 
in  which  coitus  has  been  practised  immediately  through  the  os 
uteri,  and  impregnation  and  undisturbed  gestation  have  followed 
in  spite  of  the  existence  of  irreducible  procidentia. 

The  causes  have  been  explained  which  tend  to  oppose  the  return 
of  any  long-existing  procidentia  of  the  uterus ;  and  the  same  causes, 
though  operating  in  a  less  degree  in  simple  prolapsus,  yet  often 
interfere  with  the  complete  restoration  of  the  womb  to  its  normal 
situation.  By  degrees,  indeed,  a  woman  not  infrequently  gets 
habituated  to  the  discomforts  of  her  position,  till  at  length  she 
seems  to  be  but  little  inconvenienced  by  them,  and  this  even  in 
cases  of  external  procidentia  of  the  womb.  To  this,  liowever, 
there  are  many  exceptions  ;  and  the  ulcerations  of  the  surface  of 
the  procident  organ  sometimes  become  very  extensive,  assume  an 
unhealthy  condition,  and  partial  sloughings  of  the  integument  take 
place  ;  or  the  mass  having  been  unreturned  longer  than  usual,  it 
becomes  swollen,  tense,  and  painful,  and  all  attempts  at  replacing 
it  prove  unavailing.  The  extreme  pain,  which  in  some  of  these 
cases  attends  upon  any  endeavor  to  replace  the  womb,  is  often  due 
to  some  degree  of  inflammation  having  been  set  up  in  the  perito- 
neum lining  the  pouch  into  which  the  intestines  descend,  at  the 
upper  and  back  part  of  the  prolapsed  womb,  or  of  the  peritoneal 
investment  of  the  intestines  themselves  ;  and  death  may  in  these 
circumstances  take  place,  wnth  many  symptoms  of  the  same  kind 
as  attend  upon  fatal  strangulated  hernia. 

Of  the  two  varieties  of  vaginal  prolapsiist  in  which  its  posterior 
or  its  anterior  wg^ll  is  displaced,  the  latter  gives  rise  to  by  far  the 
more  important  symptoms.  Some  degree  of  prolapsus  of  the  pos- 
terior vaginal  wall  exists,  indeed,  in  very  many  cases  of  laceration 
of  the  perineum  ;  and  a  painful  dragging  sensation  on  assuming 


VAGINAL     PROLAPSE.  143 

the  erect  posture,  leucorrlioeal  discharge,  and  discomfort  from  the 
projection  between  the  labia  of  a  small  pouch  of  vagina,  are  gener- 
ally experienced,  though  by  no  means  in  a  measure  always  pro- 
portionate to  the  amount  of  misphicement.  To  these  are  super- 
added all  the  inconveniences  of  constipation,  and  the  distress 
arising  from  the  impaction  of  scybala  in  the  rectum,  whenever  the 
lower  part  of  the  intestine  itself  becomes  dragged  down  and  pro- 
lapsed ;  while,  whenever  the  ailment  is  of  long  standing,  or  con- 
siderable in  degree,  the  uterus  is  usually  drawn  down  also  out  of 
the  pro})er  position. 

The  prolapsus  of  the  anterior  vaginal  wall,  attended  as  it  is  by 
descent  of  the  bladder,  is  accompanied  bj'a  peculiar  dragging  sen- 
sation at  the  umbilicus,  which  is  distressing  in  proportion  as  the 
bladder  is  full ;  is  lessened,  or  ceases  altogether,  when  that  viscus  is 
completely  empty.  This  sensation  has  been  referred,  and  probably 
correctly,  to  the  stress  upon  the  suspensory  ligament  of  the  bladder, 
which  must  be  dragged  on  more  and  more  in  proportion  as  urine 
accumulates  in  the  prolapsed  pouch  of  the  organ.  The  patient  ex- 
periences, moreover,  a  constant  desire  to  pass  water,  which  very 
frequent  micturition  fails  to  relieve,  unless  pressure  be  made  from 
below  against  the  pouch  of  prolapsed  bladder,  so  as  completely  to 
empty  the  organ.  To  this  becomes  superadded  in  many  instances, 
in  the  course  of  time,'  an  altered  condition  of  the  urine,  which  is 
turbid,  ropy,  sometimes  ofl'ensive,  and  loaded  w'ith  phosjihates; 
owing,  in  part,  to  its  retention  in  the  prolapsed  pouch  of  the  blad- 
der ;  in  part,  also,  to  irritation  propagated  to  the  kidneys  them- 
selves. •  It  can  scarcely  be  necessary  to  say  that  in  these  cases 
the  ordinary  symptoms  of  vaginal  prolapse  will  not  be  wanting; 
while  reference  h-as  already  been  made  to  the  peculiar  eifect  of 
descent  of  the  bladder  in  causing  hypertrophy  of  the  anterior  lip 
of  the  womb,  and  afterw^ards  in  occasioning  the  organ  to  prolapse. 

The  characters  of  prolapsus  of  the  uterus  or  vagina  are  so  well 
marked,  that  w'ith  the  most  ordinary  care  it  must  be  nearly  im- 
possible to  mistake  their  import.  We  may,  therefore,  pass  at  once 
to  the  examination  of  the  treatment  best  suited  to  effect  its  cure. 

Here,  however,  we  at  once  meet  with  vary  contradictory  oi)inions 
and  assertions,  for  while  some  writers  advocate  the  general  em- 
j»loyment  of  mechanical  means  to  keep  the  misplaced  organs  in 
their  proper  position,  others  deny  their  utility,  and  allege  various 
arguments  ngainst  them.  Witliout  entering  into  the  controversy, 
we  must  bear  in  mind,  what  the  disputants  have  too  often  forgotten, 
that  })rolapsns  of  the  womb  occurs  in  very  ditierent  circumstances; 
and  that  its  treatment,  to  be  appro{)riate,  must  differ  too.  Some- 
times it  is  the  result  of  causes  which  add  to  the  weight  of  the 
uterus,  and  thus  render  its  ordinary  supports  unequal  to  maintain 
it  in  its  proper  position,  while  in  other  instances  a  weakening  of 

1  To  this  CHiisp  of  alteration  of  the  urino  attention  was  first  called  by  the  late 
Dr.  Guiding  Bird,  in  a  jiajier  published  in  Medical  Times  a>ui  Oazelie,  1853,  Jan.  1, 
p.  11. 


144  TREATMENT    OF 

tlie  supports  themselves,  by  accident  or  disease,  is  the  first  step 
towards  producing  the  misplacement;  and  according  as  the  one  or 
the  other  of  these  conditions  predominates  will  the  use  of  mechani- 
cal means  be  expedient  or  undesirable.  Thus,  for  instance,  time, 
and  care,  and  judicious  management  generally  sufltice  to  remove 
that  form  of  descent  of  the  womb  which  succeeds  to  miscarriage 
or  to  labor,  wherein  the  as  yet  iniperfect  involution  of  the  organ, 
and  its  consequent  increase  of  weight,  are  the  main  causes  of  its 
misplacement,  while  mechanical  contrivances  are  always  needed 
when  the  support  which  the  vagina  should  afford  has  been  destroyed 
by  extensive  laceration  of  the  perineum,  or  greatly  enfeebled  by 
the  atrophy  of  old  age. 

The  first  inquiry,  then,  which  we  ought  to  make  in  every  case 
of  prolapsus  uteri  concerns  the  cause  to  which  the  misplacement 
of  the  organ  is  due ;  and  we  must  therefore  endeavor  to  ascertain 
the  precise  condition  of  the  patient's  liealth  previous  to  the  occur- 
rence of  those  symptoms  for  wliich  she  now  seeks  our  help.  In 
married  women  we  shall  often  find  the  commencement  of  the  evil 
referred  to  some  miscarriage  or  labor;  in  the  unmarried,  to  exer- 
tion too  severe  or  too  prolonged  at  a  menstrual  period,  and  subse- 
quently aggravated  by  a  like  want  of  care  at  each  successive  return 
of  the  menses.  Rest  in  the  recumbent  position,  strict  attention  to 
the  condition  of  the  bowels,  the  cold  hip-bath,  and  astringent 
vaginal  injections,  will  usually  suffice  for  the  cure  of  such  cases; 
and  as  the  hypertrophy  of  the  womb  gradually  subsides,  so  will 
the  organ  by  degrees  regain  its  proper  position.  Neglect  of  due 
precaution  at  the  menstrual  periods,  leading  as  it  often  does  to  the 
minor  degrees  of  uterine  prolapse,  becomes  associated,  also,  with 
enlargement  of  the  womb,  which  disappears,  together  with  the 
malposition,  under  the  same  treatment  as  is  appropriate  in  those 
cases  where  the  ailment  succeeds  to  delivery.  Here,  however, 
especial  care  is  needed,  at  the  return  of  each  menstrual  period,  to 
counteract  the  tendency  of  the  womb  to  become  again  displaced — 
care,  too,  which  it  is  often  very  diflicult  to  induce  our  patient,  who 
probably  feels  but  little  discomfort,  to  observe.  It  is  by  such  care, 
however,  rather  than  by  much  positive  treatment,  that  we  can  best 
succeed  in  putting  a  stop  to  that  over-profuse  menstruation  which 
is  very  frequently  associated  with  even  the  minor  degrees  of  pro- 
lapsus. The  misplacement  of  the  organ  exposes  it  to  irritation ; 
the  irritated  and  congested  organ  becomes  somewhat  increased  in 
size ;  and  from  its  vessels,  larger  and  more  numerous  than  when 
the  organ  was  in  its  natural  position,  blood  flows  more  freely,  and 
all  the  more  so  if  the  patient  retains  at  these  times  the  erect  pos- 
ture, or  pursues  her  ordinary  avocations. 

In  many  other  conditions  the  uterus  grows  larger  and  heavier 
than  natural,  and  in  some  of  them,  the  disposition  to  prolapsus  is 
even  greater  tlian  when  the  size  of  the  organ  is  due  to  the  incom- 
pleteness of  its  puerperal  involution.  The  womb,  though  left  after 
delivery  much  larger  and  heavier  than  natural,  is  not  the  only  part 
hypertrophied ;  but  its  supports,  albeit  overstretched  and  conse- 


PROLAPSUS    UTERI.  145 

quently  enfeebled,  have  grown  too,  and  are  larger  and  more  power- 
ful thiin  in  the  unimpregnated  state.  If,  however,  the  increase  of 
the  womb  is  due  to  some  other  cause,  such  as  the  congestion  of 
habitual  monorrhagia,  or  the  enlargement  which  attends  upon 
chronic  inflammation,  prolapsus  of  the  organ  will  be  still  more 
likely  to  occur,  since  its  increase  of  weight  will  have  been  un- 
associated  with  any  corresponding  development  of  those  parts  by 
which  it  is  retained  in  situ.  The  prolapsus  here  is  purely  second- 
ary; the  enlarged  womb  may  even  require  local  depletion  t<f  reduce 
its  bulk,  and  till  this  end  has  been  attained,  the  prolapsus  will  tend 
to  increase,  while  attempts  to  retain  the  organ  mechanically  in  its 
proper  position  will  increase  its  irritation,  and  thus  prove  positively 
injurious. 

If  to  these  cases  we  add  another  large  class,  in  which  the  descent 
of  the  uterus  is  but  slight,  and  is  either  one  result  of  a  general  loss 
of  tone  in  the  parts,  attendant  on  a  state  of  debility,  or  the  con- 
sequence of  some  accidental  and  temporary  cause,  such  as  the  over- 
exertion of  a  long  walk,  or  excessive  fatigue,  we  may  conclude  tliat 
the  employment  of  mechanical  support  for  the  misplaced  womb  is 
not  necessary  nor  suitable: 

1st.  In  slight  degrees  of  uterine  prolapse. 

2d.  In  cases  where  the  descent  of  the  womb,  still  comparatively 
recent,  is  due  to  the  persistence  of  the  state  of  puerperal  hyper- 
trophy, owing  to  imperfect  involution  of  the  organ  after  abortion 
or  labor. 

3d.  In  cases  where  uterine  disease  of  whatever  kind  was  the 
occasion  of  the  misplacement  of  the  organ,  such  disease  being  still 
in  a  stage  calling  for  treatment. 

On  the  other  hand,  mechanical  means  of  some  kind  or  other  are 
generally  a[)[)ropriate : 

Irit.  In  all  cases  of  external  prolapse,  or  procidentia  of  the  uterus. 

2d.  In  cases  of  long-standing  prolapse  in  the  second  degree, 
associated  with  much  relaxation  of  the  vagina,  and  consequent 
weakening  of  the  uterine  supports. 

3d.  In  all  cases  of  extensive  laceration  of  the  perineum,  and,  for 
a  similar  reason,  in  cases  of  prolapsus  in  the  aged. 

4th.  In  cases  of  the  minor  degrees  of  prolapsus  which  are  ac- 
companied by  extreme  distress  or  violent  pain. 

5tli.  In  all  cases  of  considerable  prolapsus  of  the  vagina,  with  or 
without  descent  of  the  rectum  or  bladder;  and  in  all  cases  in  which 
the  uterine  prolapsus  is  secondary  to  any  of  those  other  forms  of 
mis])lacement. 

The  supports  which  are  used  in  these  cases  are  intended  cither 
to  koc})  the  womb  in  its  proper  position,  or  to  atford  relief  to  the 
painful  sensations  that  accompany  its  misplacement. 

They  are  cither  internal  or  external,  the  latter  being  various  de- 
scriptions of  bandages  which  exert  counterpressure  in  ditlerent 
ways  on  the  sacrum,  the  perineum,  or  even  tho*pn1)os;  while  the 
former  act  immediately  on  the  displaced  organs  themselves.  The 
internal  are  called  pessaries,  from  the •  Greek -e^ffcn;  the  ancients 

10 


146  INDICATIONS    FOR     EMPLOYMENT    OF 

being  accustomed  to  introduce  medicated  substances  for  various 
purposes  into  the  vagina.^ 

There  are  two  different  kinds  of  pessaries;  namely,  those  which 
when  introduced  are  maintained  in  their  position  by  the  vaginal 
walls  themselves,  and  those  whose  support  is  external  to  the  vagina, 
and  supplied  by  means  of  a  bandage  or  some  similar  contrivance 
to  which  they  are  attached  by  means  of  a  stem.  Each  of  these 
kinds  has  its  advantages  in  certain  cases,  while  obviously  we  have 
no  choice  but  to  employ  the  latter  in  many  instances  where  the 
perineum  has  been  so  torn  as  greatly  to  enlarge  the  orifice  of  the 
vagina,  and  thus  to  render  its  walls  incapable  of  retaining  the 
pessary. 

A  pessary  ought  to  be  light  and  smooth,  in  order  that  by  its 
weight  it  may  not  further  weaken  the  lax  and  yielding  vaginal 
walls,  nor  increase  leucorrhoeal  discharge  by  its  irritating  qualities. 
It  is  also  desirable  that  it  should  not  press  unequally,  nor  upon  a 
very  limited  extent  of  the  vaginal  wall,  but  that  the  support  it 
gives  should  be  uniform,  and  distributed  over  a  tolerably  large 
surface.  Xow  these  conditions  are  best  fulfilled  by  a  pessary  of  a 
globular  or  slightly  oval  form,  and  made  of  wood  or  some  other 
material  to  which  a  perfectly  smooth  surface  can  readily  be  given. 
Hollow  metallic  pessaries  have  been  recommended  by  some  writers, 
and  whenever  it  is  expedient  for  them  to  be  habitually  worn,  the 
lightness,  perfect  cleanliness,  and  unirritating  qualities  of  a  thin 
globe  of  electro-gilt  silver  render  it  by  far  the  best  pessary  that 
can  be  employed.  The  expense  of  employing  any  of  the  precious 
metals  must,  however,  always  be  a  bar  to  their  general  use;  while 
pessaries  of  box-wood  answer  every  important  purpose  when  a 
temporary  support  only  is  needed.  Indian-rubber  has  many  ad- 
vantages in  its  softness  and  elasticity,  but  it  is  by  no  means  so 
cleanly  as  wood,  and  is  easily  acted  on  by  the  vaginal  secretions. 
The  globular  pessary  is  especially  useful  in  cases  of  prolapse  in 
the  first  degree,  where  the  descent  of  the  womb,  so  that  its  cervix 
rests  upon  the  floor  of  the  vagina,  causes  much  local  suftering,  or 
much  sympathetic  disturbance.  A  small  globular  pessary  intro- 
duced into  the  cul-de-sac  behind  the  womb,  sufiices  to  keep  the 
organ  off  the  pelvic  floor,  and  often  affords  the  patient  a  degree  of 
comfort  equally  grateful  and  unexpected,  and  removes  symptoms 
such  as  we  could  scarcely  persuade  ourselves  that  so  very  slight  a 
degree  of  misplacement  of  the  womb  should  have  produced.    The 

'  It  was  for  the  medicinal  virtues  of  their  composition,  not  for  their  mechanical 
utility,  that  these  pessaries  were  employed  by  the  ancients.  Thus,  for  instance, 
in  the  Hippocratic  oath  the  candidate  vows  to  abstain  from  the  use  of  pessaries  to 
destroy  the  fojtus ;  and  it  is  to  the  supposed  remedial  virtues  of  their  constituents 
that  Celsus  refers  in  the  twenty-first  chapter  of  his  fifth  book.  Their  name  is  de- 
rived by  some  from  their  supposed  therapeutical  power,  quasi  Trtvo^nv  viollire ;  but 
\)y  others  from  ^ea-KCf  the  skin  of  an  animal  with  the  wool  on  it,  in  which  the 
materials  of  the  pessary  were  wrapped  previous  to  being  introduced  within  the 
vulva.  These  pessaries  were  employed  in  cases  of  prolapsus  uteri,  but  as  a  means 
of  applying  astringent  remedies,  rather  than  of  mechanically  retaining  the  uterus 
in  its  position;  and  it  is  only  within  the  past  two  centuries  that  their  mechanical 
utility  has  come  to  be  chiefly,  if  'not  exclusively  regarded. 


MECHANICAL    SUPPORT.  147 

large  globular  pessary  is  also  very  useful  in  cases  of  considerable 
and  long-standing  prolapsus  of  the  uterus,  in  which  the  organ  is 
close  to  the  external  parts,  or  even  protrudes  beyond  them,  while 
the  whole  of  the  vaginal  wall  is  in  a  state  of  extreme  relaxation, 
lu  some  of  these  cases,  indeed,  as  well  as  in  others  where  the 
perineum  has  been  extensively  torn,  it  may  be  necessary  to  retain 
the  pessary  by  means  of  an  external  bandage  with  a  pad  pressing 
on  the  perineum.  In  e-very  instance  of  considerable  prolapsus  of 
the  vagina,  and  in  all  cases  where  the  rectum  or  bladder  is  pro- 
lapsed, an  oval  pessary  is  absolutely  needed  to  prevent  the  increase 
of  the  ailment,  and  to  bring  about  its  cure.  The  globular  pessary, 
however,  is  not  free  from  some  disadvantages.  Unless  it  be  very 
small,  or  unless  the  patient  learn  to  introduce  and  remove  it  for 
herself, — a  matter,  indeed,  seldom  of  much  difficulty, — it  not  only 
interferes  with  sexual  intercourse,  but  also  with  such  an  efficient 
use  of  vaginal  injections  as  is  necessary  for  purposes  of  cleanliness. 
It  is  partly  with  a  view  to  obviate  the  difficulties  which  a  person 
sometimes  experiences  in  the  introduction  and  withdrawal  of  the 
pessary,  that  air-pessaries  have  of  late  been  invented,  composed 
of  bags  of  vulcanized  Indian-rubber,  with  a  tube  attached  to  them ; 
through  which,  having  been  introduced  in  the  flaccid  state,  they 
may  be  distended  with  air  by  means  of  a  syringe.  They  are  ex- 
pensive, and  apt  to  get  out  of  order,  but  I  know  of  no  other  draw- 
back from  their  utility.  In  some  instances  there  is  a  very  con- 
siderable degree  of  tenderness  of  the  uterus  and  vagina,  so  that 
an  ordinary  wooden  pessary  occasions  much  pain,  and  when  this 
is  the  case  the  Indian-rubber  air-pessary  will  be  found  extremely 
serviceable.  Besides  the  more  costly  form  of  it,  which  is  inflated 
by  means  of  the  syringe,  there  is  a  less  expensive  kind  which  re- 
sembles an  ordinary  pessary,  except  that  it  is  distended  with  air, 
instead  of  being  stuft'ed  with  horse-hair  or  any  other  material. 

I  ouglit,  perhaps,  to  say  a  word  or  two  about  the  use  of  pessaries 
made  of  sponge,  and  which,  though  less  employed  than  they  once 
were,  are  not  without  their  application  in  some  instances.  The 
employment  of  globular  pieces  of  sponge  enveloped  in  oiled  silk, 
to  render  them  impervious  to  the  vaginal  secretions,  has  now  tallen 
into  disuse,  owing  to  the  superior  advantages  of  Indian-rubber 
pessaries.  When  used  now,  therefore,  the  sponge  is  introduced 
either  without  any  covering,  or  inclosed  in  a  piece  of  linen.  The 
advantages  of  the  sponge  pessary  consist  in  the  facility  of  its  in- 
troduction, which  the  patient  can  always  manage  for  herself,  and 
in  the  circumstance  that  it  expands  so  as  eftectually  to  keep  the 
uterus  in  situ,  and  that  astringent  vaginal  injections  may  be  used 
without  its  removal.  The  objections  to  it  are,  that  its  rough  sur- 
face is  always  apt  to  irritate  the  vaginal  walls,  while  by  imbibing 
the  discharges,  it  grows  rapidly  very  offensive  and  proportionally 
more  irritating.  On  these  accounts,  therefore,  it  is  never  to  be 
em}»loyed  among  the  poor,  whose  circumstances  are  likely  to  in- 
terlere  with  the  most  scrupulous  cleanliness,  nor  in  any  case  where 
there   is   difficulty   in  retaining  the  uterus  in  its  place;  while 


148  MECHANICAL  SUPPORTS. 

wherever  it  is  used,  the  sponge  ought  to  be  withdrawn  every 
twelve  hours  and  another  substituted  for  it,  and  no  sponge  should 
be  reintroduced  till  after  it  has  been  soaked  for  twelve  hours  in 
water.  The  only  cases  then  in  which  sponge  is  advisable  as  a 
pessary,  are  cases  of  the  minor  degrees  of  prolapse,  where  we  are 
fearful  lest  the  evil  should  be  increased  by  the  patient's  ordinary 
pursuits  and  exercise,  while  the  use  of  a  pessary  is  a  precautionary 
measure,  which  there  is  good  reason  to  expect  that  we  may  in  a 
short  time  be  able  to  dispense  with  altogether. 

Another  kind  of  pessary,  not  so  generally  applicable  as  that  of 
a  globular  or  oval  form,  but  yet  having  advantages  that  render  it 
verj'  useful  in  some  cases,  is  the  disk  pessary.  This,  as  its  name 
implies,  is  a  flat  disk  of  wood,  or  sometimes  of  some  light  material, 
such  as  hair  or  wool  covered  with  Indian-rubber,  or  even  an  Indian- 
rubber  cushion  inflated  with  air,  which  being  introduced  into  the 
vagina,  is  placed  transversely  across  between  the  spines  of  the 
ischia,  so  as  to  form  an  artificial  floor  to  the  pelvis,  and  thus  keep 
the  uterus  more  nearly  in  its  natural  situation.  These  pessaries 
are  all  perforated  with  a  central  opening,  which  is  not  merely 
useful  in  facilitating  their  removal,  but  also  allows  the  ready  escape 
of  the  menstrual  fluid,  and  even  admits  the  possibility  of  conception 
taking  place,  while  they  are  still  worn  by  the  patient.  The  central 
aperture,  however,  has  sometimes  been  the  occasion  of  consider- 
able discomfort  to  the  patient,  owing  to  the  cervix  uteri  passing 
through  it  and  becoming  swollen,  and  partially  strangulated  by  its 
edges.  This  inconvenience  is  easily  avoided  by  the  precaution  of 
having  the  central  aperture  made  either  too  small  for  the  cervix 
to  pass  through  it,  or  too  large  for  the  possibility  of  its  strangula- 
tion occurring ;  and,  as  a  general  rule,  the  former  mode  of  con- 
struction is  preferable  to  the  latter.  A  less  remediable  objection 
to  this  kind  of  pessary  is  furnished  by  its  extreme  liability  to  be- 
come displaced,  owing  to  the  circumstance  that  it  is  in  contact 
with  only  a  comparatively  narrow  band  of  vaginal  wall,  instead  of 
being  embraced,  as  the  globular  pessary  is,  b}''  a  large  extent  of 
surface  ;  while,  though  a  woman  possessed  of  very  slight  dexterity 
may  learn  to  introduce  and  remove  the  globular  pessary  for  herself, 
she  must  always  be  dependent  on  a  medical  man  for  the  proper 
adjustment  of  a  disk-shaped  pessary. 

Many  endeavors  have  been  made  to  overcome  by  modifications 
of  the  instrument  this  last  objection  to  the  disk-shaped  pessary, 
and  to  provide  a  support  for  the  uterus  which,  while  easy  of  in- 
troduction, shall  yet  be  little  liable  to  become  misplaced.  These 
ends  appear  to  have  been  at  length  attained  by  the  ingenuity  of 
Dr.  Zwanck,^  of  Hamburg.  His  instrument,  which  is  now  readily 
obtainable  in  London,  consists  of  two  hollow  oval  disks  of  metal, 
with  a  central  opening  in  each  to  diminish  their  weight,  and 
united  by  a  hinge,  so  that  they  can  be  closed  or  expanded.     A 

1  He  published  a  description  and  a  drawing  of  the  instrument  in  the  Monaischrift 
f.  Geburtskunde,  Band  i,  Heft  3. 


VAKIETIES  OF  PESSARIES.  149 

small  curved  stem  proceeds  from  near  the  hinge  end  of  each  disk, 
which,  when  the  instrument  is  expanded,  come  into  contact  with 
each  other,  and  are  easily  fixed  by  a  screw  which  forms  the 
slightly  bulbous  end  of  the  longer  stem,  and  thus  keeps  the 
pessary  securely  open.  The  instrument  is  of  course  introduced 
closed,  and  when  carried  as  high  as  it  will  readily  pass  in  the 
vagina,  it  is  expanded  by  bringing  the  stems  togther ;  a  turn  of 
the  screw  secures  it  in  this  position,  and  its  management  is  so 
simple  that  the  patient  learns  at  once  how  to  introduce  and  with- 
draw it  herself.  I  have  now  employed  it  on  several  occasions,  and 
have  been  surprised  to  find  how  eftectually  it  retains  even  the  en- 
larged womb  which  has  been  frequently  procident.  Its  introduc- 
tion is,  however,  diflicult  and  painful  in  cases  where  the  vaginal 
orifice  is  at  all  narrow,  and  it  seems  altogether  better  adapted  to 
the  relief  of  the  greater  than  of  the  slighter  forms  of  uterine  mis- 
placement ;  and  of  those  especially  in  which  the  perineum  is  torn, 
or  has  lost  its  resiliency  so  that  the  air-pessary  is  not  retained  within 
the  vagina.^ 

But  there  is  another  large  class  of  pessaries  in  which  the  instru- 
ment is  retained  in  its  position  by  some  support  external  to  the 
patient,  not  by  the  mere  counterpressure  of  the  vaginal  walls  and 
pelvic  floor.  The  principle  of  all  such  instruments  consists  in  the 
employment  of  some  kind  of  belt  surrounding  the  hips,  to  which 
either  a  stem  is  attached,  bearing  the  uterine  support,  or  else  straps 
are  connected  with  it  which  serve  to  hold  the  internal  support  in 
its  proper  position.  The  great  practical  drawback  from  their  em- 
ployment is  this,  that  the  belt  or  spring  surrounding  the  pelvis  is 
unavoidably  liable  to  slight  changes  of  position,  by  which  the 
vaginal  stem  is  sometimes  brought  to  press  painfully  on  the  orifice 
of  that  canal,  or  the  uterine  support  becomes  misplaced,  so  as  to 
allow  of  the  descent  of  the  womb  taking  place  by  its  side.  This 
circumstance,  together  with  their  much  higher  price,  leads  to  their 
being  comparatively  seldom  employed,  though  you  may  meet  with 
cases,  those  especially  in  which  the  perineum  has  been  extensively 
torn,  in  which  one  or  other  modification  of  this  kind  of  apparatus 
will  be  of  service. 

One  source  of  comfort  to  the  patient,  from  the  employment 
of  some  of  these  external  supports,  is  derived  from  the  counter- 
pressure  on  the  pelvis  which  the  belt  exercises,  and  which  relieves 
very  many  of  the  painful  sensations  experienced  in  cases  of  uterine 
prolapsus.  Two  bandages  which  seem  to  me  extremely  well 
adapted  for  this  purpose,  are  Hull's  utero-abdominal  supporter, 

*  Some  modifications  of  Zwanck's  instrument  have  been  made,  chiefly  with  the 
view  of  rendering  tiie  screw  n'lore  easily  manageable  by  the  jtatient.  iW  these 
Schilling's  is  the  most  ingenious,  since  the  two  iinibs  of  the  stem  are  never  sc]ia- 
rated  ;  but  the  instrument  is  opened  or  closed  according  as  the  screw  is  turned  from 
left  to  right,  or  from  right  to  left.  This  is  to  be  had  now  of  London  instrument- 
makers.  A  minute  description,  with  engravings  of  a  great  varii'ty  of  jiessaries, 
and  other  uterine  supports,  is  given  by  Dr.  v.  Franque,  in  his  essay  I)cr  VorJ'ail  der 
Gebiirmutler,  folio.  Wiirzburg,  18G0. 


150  MECHANICAL    SUPPORTS 

and  a  bandage  known  by  instrument-makers  as  Dr.  Asliburner's 
bandage.  Each  of  these  tightly  embraces  the  hips,  while  the 
former  is  furnished  with  a  large  padded  metallic  plate  fitting  over 
the  pubes,  and  the  latter  with  a  similar  one  adapted  to  the  upper 
part  of  the  sacrum.  The  chief  utility  of  these  metallic  plates  is 
that  by  their  firm  and  yet  gentle  counterpressnre  they  relieve  the 
sympathetic  pains  referred  to  the  back  in  one  case,  or  the  dragging 
and  distress  in  the  region  of  the  ovaries  in  another.  To  both  of 
them  a  strap  passing  between  the  legs,  with  a  perineal  pad,  is 
adapted,  and  though  it  can  be  dispensed  with  at  pleasure,  will  be 
found  of  great  service  in  all  cases  of  considerable  relaxation  of  the 
vagina,  with  disposition  to  actual  procidentia,  when  used  either 
alone,  or  in  combination  with  some  form  of  internal  support.  The 
strap  and  perineal  pad  have  the  disadvantage  of  heating  the  parts, 
and  thus  of  keeping  up  leucorrhoeal  discharge;  but  without  them 
the  instrument  cannot  be  so  well  adjusted.  Of  the  two,  that  of 
Dr.  Ashburner,  with  its  sacral  pad,  has  seemed  to  me  the  more 
useful,  greatly  relieving  the  backache,  and  being  found  indeed 
by  somiTpersons  almost  indispensable  to  their  comfort  in  walking 
or  making  any  kind  of  exertion. 

It  can  scarcely  be  necessary  to  say  much  with  reference  to  the 
manner  of  introducing  pessaries,  or  the  precautions  to  be  observed 
by  those  who  wear  them.  Even  in  cases  that  most  require  their 
employment,  it  is  always  presupposed  that  they  are  not  used  so 
long  as  any  considerable  tenderness  of  the  parts  exists,  or  as  there 
are  "any  remains  of  inflammation  or  of  considerable  congestion. 
These  conditions  being  removed,  the  patient  lying  on  her  left  side, 
the  uterus  is  carried  as  nearly  as  possible  into  its  natural  position, 
and  the  pessary,  covered  with  oil,  or  some  unguent,  is  introduced, 
not  without  attention  to  the  direction  of  the  pelvic  axes,  and  placed 
either  behind  the  cervix  uteri,  or  simply  in  the  upper  part  of  the 
vagina,  if  the  relaxation  of  the  vaginal  walls  is  ver}'^  considerable, 
and  the  prolapsus  has  passed  the  first  degree.  Whenever  the  re- 
laxation of  the  parts  is  great,  it  will  be  e&sential  to  choose  at  first 
a  pessary  so  large  as  not  to  be  introduced  through  the  orifice  of 
the  vulva  without  some  little  difficulty,  for  the  vagina  is  always 
more  capacious  near  to  its  upper  part  than  close  to  its  orifice  ;  and 
besides,  if  the  introduction  of  the  instrument  were  very  easy,  it 
would  be  almost  sure  to  become  speedily  displaced.  In  the  greater 
degrees  of  prolapsus,  and  when  the  perineum  is  torn,  an  external 
bandage  with  a  perineal  pad  is  required  to  keep  the  instrument 
in  its  place. 

When  the  disk  pessary  is  employed,  the  instrument  is  intro- 
duced edgewise,  and  is  carried  up  in  the  vagina  as  far  as  possible 
in  that  position.  It  is  then  fixed  by  turning  it  round  so  as  to  bring 
it  to  lie  transversely  between  the  ischiatic  spines,  when  it  forms  a 
sort  of  artificial  pelvic  fioor,  on  which  the  uterus  rests.  Which- 
ever kind  of  pessary  is  used,  but  especially  when  the  disk  pessary 
is  employed,  we  should  not  leave  our  patient  after  its  introduction 
until  she  has  walked  two  or  three  times  across  the  room,  and  thus 


AND    PESSARIES.  151 

ascertained  that  the  instrument  still  remains  in  its  proper  position. 
Its  small  liability  to  misplacement  is,  as  I  have  already  stated,  one 
of  the  great  advantages  of  Zwanck's  instrument. 

No  pessary  should  be  allowed  to  remain  for  many  weeks  in  the 
vagina,  whatever  may  be  the  precautions  used  by  frequent  employ- 
ment of  vaginal  injections  to  prevent  the  deposit  of  the  secretions 
upon  it.  One  of  the  great  advantages  of  the  globular  or  cylindrical 
pessary,  and  also  of  Zwanck's  instrument,  consists  in  the  possibility 
of  its  being  removed  by  the  patient  herself  every  night,  and  re- 
placed before  she  rises  in  the  morning,  by  which  means  not  only 
can  it  be  kept  scrupulously  clean,  but  the  vagina  can  be  washed 
out  by  the  copious  use  of  water,  or  of  some  astringent  lotion  twice 
in  the  twenty-four  hours.  Cases  of  most  serious  mischief,  arising 
from  the  neglect  of  this  precaution,  are  on  record,  in  which  in- 
flammation and  ulceration  of  the  vagina  have  been  produced,  or 
the  pessary  has  even  made  its  way  into  the  bladder,  thus  entailing 
on  the  patient  all  the  miseries  of  vesico-vaginal  fistula.  But  an- 
other reason  for  the  frequent  removal  of  a  pessary  is,  that  in  many 
cases  we  employ  it  j)urely  as  a  temporary  expedient,  as  a  means 
of  keeping  the  womb  in  its  place,  while  the  vagina  and  the  dupli- 
catures  of  peritoneum  are  acquiring  that  power  which  may  enable 
them  permanently  to  retain  it  there.  We  hope  that  after  a  time 
the  pessary  may  be  altogether  dispensed  with,  and  as  a  preliminary 
step  towards  this,  we  change  the  pessary  occasionally,  and  substi- 
tute a  smaller  instrument  for  that  which  was  previously  worn.  It 
is  indeed  comparatively  seldom  expedient  to  do  away  with  the  use 
of  the  pessary  all  at  once;  but  it  is  in  general  more  prudent  to 
employ  one  or  more  instruments  of  smaller  size  before  discarding 
their  use  altogether. 

In  cases  of  prolapsus  of  the  rectum,  it  is  important  to  give  the 
patient  special  cautions  as  to  the  necessity  of  attending  to  the  state 
of  her  bowels,  and  a's  to  the  probability  that  a  few  weeks  of  neglect 
in  that  respect  would  reproduce  all  her  former  symptoms.  When 
the  bladder  has  been  misplaced,  something  may  be  done  to  cure 
the  slighter  degrees  of  the  accident,  or  after  the  removal  of  the 
pessary  to  prevent  its  return,  by  the  patient  pressing  with  her 
fingers  against  the  anterior  vaginal  wall  whenever  she  passes 
water,  so  as  to  insure  on  each  occasion  the  complete  emptying  of 
the  bladder. 

In  all  cases  of  procidentia  of  the  uterus,  as  well  as  of  external 
prolapse  of  the  vagina,  the  first  point  to  attend  to  is  to  return  the 
parts  within  the  pelvic  cavity,  and  to  keep  them  there  hy  the 
employment,  if  necessary,  of  Ashburner's  or  of  some  other  well- 
adjusted  bandage  with  a  perineal  pad.  In  some  instances^,  wlien 
the  procidentia  has  been  of  very  long  standing,  this  is  all  that  can 
for  a  time  be  attempted,  since  the  amount  of  hypertrophy  of  the 
womb  and  of  the  adjacent  parts  is  not  infrequently  so  considerable 
as  to  leave  little  room  for  the  enq)loyment  of  a  iiossary.  It  is  re- 
markable, however,  with  what  rajtidity  such  hypertrophy  diminishes 
if  the  patiejit  is  kept  for  two  or  three  weeks  perfectly  quiet  in  tlie 


152  EULES    FOR    USE    OF    PESSARIES. 

recumbent  posture,  while  care  is  taken  that  the  prolapsus  does  not 
become  again  external.  The  presence  even  of  very  considerable 
abrasion  about  the  os  uteri  does  not  in  any  measure  contraindicate 
the  immediate  return  of  the  organ,  nor  do  in  general  the  large 
and  indoleiU  ulcerations  which  form  upon  the  surface  of  the  in- 
verted vagina.  The  healing  of  such  sores,  though  always  tardy, 
yet  usually  goes  on  much  more  rapidly  within  the  body  than 
external  to  it,  while,  if  cicatrization  do  not  advance  satisfactorily 
under  the  use  of  simple  vaginal  injections,  such  as  the  lead  wash, 
or  the  lotio  nigra,  the  patient  can  be  directed  to  protrude  the  uterus 
externally  by  occasional  bearing  down  efforts,  in  order  to  enable 
us  to  touch  the  edges  or  surface  of  any  ulcer  that  may  require  it 
with  the  nitrate  of  silver. 

To  this  rule,  however,  there  are  occasional  exceptions.  Some- 
times the  exposed  surface  has  become  extensively  abraded,  and  is 
very  painful,  or  the  ulcerations  upon  it  are  large,  numerous,  and 
unhealthy.  In  such  circumstances  the  endeavor  to  replace  the 
uterus  would  be  very  painful,  while  the  ulcerations  may  require 
more  direct  treatment  than  would  be  practicable  if  the  organ  were 
returned  within  the  pelvic  cavity.  When  this  is  the  case  I  am 
accustomed  to  keep  the  patient  for  a  few  days  strictly  in  the  recum- 
bent posture,  with  the  hips  raised,  and  the  uterus  itself  supported 
on  a  pillow,  and  enveloped  either  in  simple  water-dressing  or  in  a 
weak  lead  lotion,  or  if  the  abrasion  of  its  surface  be  very  extensive, 
and  the  discharge  from  it  very  profuse,  in  cloths  soaked  in  a  lotion 
composed  of  two  scruples  of  the  oxide  of  zinc,  suspended  by  means 
of  two  drachms  of  mucilage,  in  six  drachms  of  water.  If  the  sores 
are  very  indolent  they  may  be  dressed  with  an  ointment  of  two 
drachms  of  Peruvian  balsam  to  an  ounce  of  spermaceti  ointment, 
while  their  edges  may  require  daily  touching  with  the  solid  nitrate 
of  silver.  These  measures,  however,  are  to  be  continued  only  so 
long  as  the  state  of  the  procident  parts  absolutely  requires  it,  for  the 
sooner  they  can  be  replaced  the  better  it  is  in  all  respects.  Two 
other  conditions  require  caution  in  the  endeavor  to  replace  the 
womb,  or  delay  in  attempting  it.  When  the  uterus  has  long  been 
external,  the  intestines,  as  already  explained,  fall  down  out  of  their 
proper  situation  into  the  pelvic  cavity.  They  may  grow  so  habit- 
uated to  their  new  position  that  considerable  discomfort  may  be 
experienced  by  the  patient  when  the  womb  is  replaced.  In  these 
circumstances  it  will  be  advisable  to  return  the  organ  for  a  short 
period  only  every  day,  so  as  by  degrees  to  accustom  the  parts  to  the 
disturbance  of  what  has  now  become,  by  the  lapse  of  time,  almost 
their  natural  position.  The  discomfort,  however,  that  the  patient 
experiences,  may  be  further  due  to  the  circumstance  that  adhesion 
has  taken  place  between  the  intestines  themselves,  or  between  them 
and  the  margins  of  the  sac  of  the  prolapsus,  thus  offering  a  posi- 
tive mechanical  impediment  to  the  replacement  of  the  womb,  and 
calling  for  much  care  on  our  part,  since  not  discomfort  only,  but 
dangerous  peritonitis,  may  result  from  too  forcible  efforts  to  return 
the  womb,  or  when  replaced,  to  keep  it  constantly  within  the 


MANAGEMENT    OF    CHRONIC    PROCIDENTIA.  153 

pelvis.  In  all  cases,  too,  of  very  large  prolapsus,  in  which  the 
intestines  have  descended  into  the  sac,  much  caution  is  necessary 
in  any  attempt  at  replacing  the  womb.  If  there  be  much  tender- 
ness of  the  mass,  it  may  be  expedient  to  apply  leeches  to  it,  and 
to  keep  fomentations  or  water-dressing  upon  it  for  many  days. 
But  even  in  the  absence  of  any  such  symptom  it  is  yet  expedient, 
unless  the  mass  is  returned  with  great  facility,  to  content  ourselves 
for  a  time  with  raising  the  uterus  by  means  of  a  pad,  and  apply- 
ing a  T  bandage  to  prevent  its  further  descent ;  for  if  by  gentle 
means  we  can  gradually  diminish  the  prolapsus,  we  may  hope  in 
the  course  of  time  safely  to  remove  it  altogether.  By  an  opposite 
course  of  proceeding,  so  much  violence  will  almost  invariably  be 
done  to  the  intestines  as  to  excite  their  inflammation ;  and  I  have 
seen  death  on  one  occasion  result  from  this  want  of  precaution, 
while  in  another  instance,  though  no  excessive  violence  was  used 
in  replacing  the  organ,  peritonitis  supervened,  from  which,  liow- 
ever,  the  patient  happily  recovered. 

The  various  contrivances  for  the  relief  of  prolapsus  of  the  uterus 
or  vagina  which  we  have  hitherto  examined,  are  confessedly  merely 
palliative  measures;  bringing  about  a  cure,  indeed,  in  many  in- 
stances, but  doing  so  indirectly  by  preventing  any  increase  of  the 
displacements,  and  thus  giving  time  and  opportunity  for  nature 
gradually  to  remove  them.  In  the  slighter  degrees,  and  in  com- 
paratively recent  cases  of  prolapsus,  these  means  seldom  fail  to 
accomplish  much  good ;  but  there  is  an  uncertainty  about  their 
results  when  the  accident  is  of  long  standing,  or  very  considerable, 
which  has  led  not  unnaturally  to  the  endeavor  more  speedily  and 
more  surely  to  accom})lish  a  cure. 

Numerous  operations  have  therefore  been  devised,  having  in 
view  either  the  diminution  of  the  orifice  of  the  vulva,  and  the  con- 
sequent prevention  of  external  prolapsus,  or  the  contraction  of  the 
vagina  itself,  and  thereby  the  removal  of  one  of  the  chief  causes 
on  which  the  prolapsus  depends.  There  can,  probably,  be  no  dit- 
ference  of  opinion  with  reference  to  the  propriety  of  performing 
an  operation  in  some  of  these  cases.  In  those,  for  instance,  where 
extensive  laceration  of  the  perineum  has  been  followed  by  pro- 
lapsus of  the  vagina  or  rectum,  and  by  consequent  descent  of  the 
uterus,  it  is  obvious  that  all  mechanical  contrivances  for  keeping 
the  womb  in  place  will  accomplish  but  little  in  comparison  with 
what  we  may  hope  to  do  by  restoring  the  perineum,  giving  to  the 
vagina  once  more  its  proper  support,  and  bringing  the  parts  again 
into  their  natural  condition.  Between  this,  however,  and  the  arti- 
ficial contraction  of  the  orifice  of  the  vulva  there  is  a  very  wide 
difierence.  The  restoration  of  the  natural  perineum  gives  l)ack  to 
the  pelvic  organs  tlie  support  of  which  accident  had  deprived  them, 
and  is  thus  essentially  a  curative  measure;  the  partiid  ol)literation 
of  the  vulva  does  no  more  than  mechanicall}' to  close  the  opening 
through  which  the  prolapsed  organs  had  escaped  from  the  pelvic 
cavity;  while  it  leaves  all  the  other  evils  of  the  accident  unmiti- 
gated, and  even  less  amenable  to  palliative  measures,  and  to  such 


154  OPERATIONS    FOR    THE    CURB 

aid  as  mechanical  contrivance  can  afford,  than  tliey  were  before. 
In  spite  of  these  obvious  drawbacks,  however,  the  difficulties  at- 
tendant on  the  application  of  pessaries  and  other  mechanical  sup- 
ports, the  discomforts  inseparable  from  their  employment,  and 
their  insufficiency,  in  some  instances  at  least,  to  answer  even  that 
limited  purpose  which  alone  they  can  fulfil,  led  to  the  suggestion 
by  Mende^  of  one  operation,  and  to  the  performance  by  Fricke^ 
of  a  somewhat  different  one,  with  the  object  of  retaining  the  uterus 
within  the  vagina.  Mende's  operation,  which  was  intended  to  re- 
tain the  womb  by  forming  an  artificial  hymen,  was  never  practised, 
but  the  attention  which  has  been  excited  in  this  country  by  the 
performance  of  an  operation  identical  in  principle  to  that  of  Fricke 
renders  it  desirable  to  enter  somewhat  more  into  detail  concern- 
ing it  than  would  otherwise  be  expedient. 

Fricke's  operation  consists  in  the  removal  from  the  edge  of  each 
labium  of  a  portion  of  its  substance  of  two  fingers'  breadth ;  the 
incisions  being  begun  about  an  inch  below  the  superior  commis- 
sure on  either  side,  and  uniting  in  an  arched  form  half  an  inch 
behind  the  frenulum;  in  doing  which  a  special  caution  is  given 
not  to  be  too  sparing  of  integument.  The  hemorrhage  having 
ceased,  the  edges  are  united  by  sutures,  of  which  ten  or  twelve 
are  sometimes  necessary,  and  the  operation  is  completed.  The 
union  thus  obtained  was  incomplete  in  many  instances,  but  even 
then  a  sort  of  bridge  of  integument  was  formed  which  it  was  be- 
lieved by  M.  Fricke  would  prove  amply  sufficient  to  retain  the 
uterus  in  its  place.  The  operation,  too,  was  speedily  adopted  by 
others,  and  Dieffenbach  lent  the  great  weight  of  his  reputation  in 
its  support.  But  nevertheless,  "though  the  proceeding  had  ap- 
parently taken  firm  root  in  surgical  practice,  and  though  it  had 
been  most  carefully  performed  by  dexterous  hands,  the  lapse  of 
time  sufficed  to  moderate  the  highflown  expectations  which  had 
been  entertained  concerning  it,  and  a  calm  judgment  succeeded, 
which  we,"  says  Professor  Kilian,  "after  having  performed  the 
operation  five  times,  pronounce  without  the  least  hesitation.  It 
may  be  regarded  as  established, — 1st,  That  the  operation  in  some, 
though  very  rare  cases,  is  of  permanent  service.  2d,  That  in  not 
a  few  other  cases  it  is  likewise  of  temporary  utility,  sufficing  to  re- 
tain the  womb  for  some  weeks,  possibly  even  for  some  months, 
but  allowing  of  the  eventual  return  of  the  procidentia  as  the  orifice 
of  the  vagina  gradually  dilates;  and  Zd,  that  very  often  it  either 
fails  completely,  or  its  success  is  extremely  imperfect.  In  the  face 
of  these  evils,  Fricke's  proceeding  was  unable  to  maintain  itself 

1  Die  GcschlechtshrankheUen  des  Weibes,  Gottingen,  1834,  vol.  ii,  p.  51. 

2  Annnlen,  etc.,  vol.  ii,  1833,  p.  142  :  whence  a  minute  account  of  the  operation 
is  extracted  in  Kilian's  Operniwndehre,  2d  ed.,  vol.  iii,  1851,  p.  95;  and  in  South 's 
edition  of  Chelius,  vol.  ii,  p.  114.  The  date  of  the  appearance  of  Mr.  South '.s  work 
was  1847  ;  that  of  Mr.  Brown'.s  work  on  Diseases  of  Wo-inen,  in  which  for  other  pur- 
poses, South 's  Chelius  is  referred  to,  is  1854;  but  by  a  singular  accident,  all  the 
details  which  Mr.  South 's  Chelius  contains,  with  reference  to  operations  for  prolap- 
sus uteri,  seems  to  have  escaped  Mr.  Brown's  notice.  See  his  letter  in  the  Medical 
Ti7nes,  April  11,  1857. 


OF    PROLAPSUS.  155 

in  practice,  and  the  various  attempts  made  to  improve  and  to 
modify  it  have  proved  altogether  unsnccessfuh"' 

Nearly  simultaneously  with  the  abandonment  of  this  operation 
on  the  continent,  an  unconscious  modification  of  it  was  introduced 
into  this  country  by  Mr.  Baker  Brown,  in  which  the  general  in- 
tegument is  left  untouched,  the  mucous  membrane  only  being 
removed  from  the  inner  surface  of  the  labia  from  a  point  on  a  level 
with  the  urethra,  and  from  the  posterior  surface  of  the  vagina,  and 
the  parts  being  then  brought  together  by  sutures,  the  orifice  of 
the  vagina  is  thus  contracted,  and  the  perineum  elongated.  This 
proceeding  is  certainly  much  les3  severe  than  that  adopted  by 
Fricke,  but  at  the  same  time  it  must  contract  the  orifice  of  the 
vulva  to  a  much  less  extent  than  the  other  operation  by  wdiich  the 
integument  is  so  freely  removed.  When,  therefore,  we  find 
Fricke's  operation,  even  as  modified  by  Malgaigne,  who  carried 
his  incisions  much  deeper,  and  removed  a  considerable  extent  of 
mucous  membrane  at  the  orifice  of  the  vagina,  in  order  to  include 
a  still  larger  surface  in  the  suture,  abandoned  on  account  of  its 
not  being  followed  by  permanent  success,  we  hesitate  to  pro- 
nounce an  opinion  on  the  alleged  successful  result  of  almost  every 
one  of  fifty  cases  in  which  the  modified  operation  was  performed 
by  one  surgeon.^ 

Frequent  as  is  procidentia  of  the  uterus  among  the  poor,  cases 
in  which  the  condition  proves  rebellious  to  rest  and  well-contrived 
mechanical  support,  are,  I  believe,  of  very  rare  occurrence.  It  is 
suprising  how^  much  the  size  of  the  procident  w'omb  is  reduced 
after  its  return  within  the  vagina  by  a  month's  rest  in  bed,  how 
completely  along-standing  ulceration  of  its  orifice  heals,  and  how 
eft'ectually  the  organ  is  retained  afterwards  within  the  pelvis  by  a 
bandage.  If  in  the  majority  of  these  cases  an  operation  were  per- 
formed, a  similar  result  would  doubtless  be  obtained;  the  month's 
compulsory  rest  in  bed  would  be  follow^ed  by  the  same  diminution 
in  the  size  of  the  uterus,  and  the  elongated  perineum  would  answer 
for  a  time  at  least  the  same  purpose  as  the  perineal  pad  of  an 
ordinary  bandage;  while  by  slow  degrees  the  ligaments  in  the  one 
case  as  in  the  other  might  regain  some  measure  of  power,  and  the 
womb  might  cease  to  fall  down  externally.  If,  however,  the  opera- 
tion be  limited  to  cases  of  special  gravity,  and  to  such  I  appreliend 
it  ought  to  be  confined,  I  doubt  whether  any  higher  commenda- 
tion can  be  bestow^ed  on  it  than  is  contained  in  the  Ilippooratic 
axiom,  which  pronounces  a  "doubtful  remedy' to  be  better  than 
none  at  all."     In  the  Only  case  of  mine  in  which,  the  perineum 

J  Kilian,  op.  cii.,  p.  99. 

2  Mo/iral  Times,  November  21,  1857.  The  value  of  the  statetnent  is  illustrated 
by  the  fact,  that  of  forty-one  cases  reported  in  the  2d  edition  of  Mr.  Brown's  work 
on  Diseases  of  ]i\imen,  pp.  101-111,  while  one  only  is  an  admitted  failure,  and  one 
aUowefl  to  bean  incom])lete  success,  there  are  but  three  of  the  remainder  concern- 
inji-  which  any  information  is  given  after  the  discharixo  of  the  jiatient  from  tlio 
hospital.  The  permanence  of  the  cure  is  the  test  of  tlie  value  of  the  operation; 
towards  establishing  that,  these  thirty-six  cases  are  absolutely  worthless. 


156  OPERATIONS    FOR    THE    CURE 

being  intact,  the  operation  seemed  requisite,  it  failed  completely 
to  retain  the  womb,  and  within  two  months  from  the  patient's 
leaving  the  hospital  the  procidentia  was  as  bad  as  ever.  The 
patient  was  a  young  unmarried  woman,  twenty-six  years  old, 
whose  spine  was  much  distorted  by  lateral  curvature,  and  to 
whom,  on  that  account,  no  bandage  could  be  adapted.  Mr. 
Paget  performed  Fricke's  operation ;  the  union  of  the  parts  was 
complete,  and  the  elongation  of  the  perineum  was  carried  further 
than  would  have  been  expedient  had  the  woman  been  married. 
The  cicatrix  yielded  to  the  pressure  from  above;  for  a  time  the 
uterus  distended  the  new  perineum,  then  bit  by  bit  it  dilated  the 
orifice  of  the  vulva,  till  at  length  it  projected  externally  as  it  had 
done  before. 

A  verdict  not  more  favorable  must  be  pronounced  on  a  kindred 
though  somewhat  different  operation,  which  has  sometimes  been 
practised  either  in  addition  to  that  for  narrowing  the  vulva,  or 
independently  of  it,  and  which  consists  in  the  endeavor  to  contract 
the  vaginal  canal,  either  by  the  removal  of  strips  of  its  mucous 
membrane,  or  by  the  employment  of  the  actual  cautery,  or  of 
strong  caustics,  so  as  to  produce  cicatrices  in  its  walls,  and  conse- 
quent shrinking  of  its  calibre,  or  by  the  insertion  of  sutures  in  its 
tissue  in  a  peculiar  manner,  with  the  view  of  obtaining  the  same 
result.  The  first  of  these  proceedings,  suggested  by  a  French  sur- 
geon, M.  Gerardin,  but  actually  performed  thirteen  years  after- 
wards by  Dr.  Marshall  Hall,  and  modified  by  Professor  Dicftcn- 
bach,  of  Berlin,  has  been  practised  more  frequently  than  the  other 
operations,  and  with  considerable  temporary  success.  The  actual 
cautery  emploj-ed  by  M.  Laugier,  and  afterwards  by  Dr.  Kennedy, 
of  Dublin,  and  the  use  of  the  strong  nitric  acid  resorted  to  by  Mr. 
Benjamin  Phillips,  have  proved  less  successful ;  while  Bellini's 
operation  by  means  of  the  suture  is  diflficult,  complicated,  and  has 
therefore  been  abandoned.  The  objection,  and,  to  my  mind,  the 
flital  objection,  to  these  as  to  the  other  surgical  proceedings  for 
the  cure  of  prolapsus  uteri,  is  furnished  not  merely  by  the  imper- 
fect nature  of  the  cure  which  they  accomplish,  and  the  new  dis- 
comforts and  inconveniences  which  they  substitute  for  those  before 
experienced,  but  still  more  by  the  want  of  permanence  in  their 
result,  even  when  their  issue  is  most  fortunate,  and  this  objection 
seems  to  me  all  the  more  serious  since  failure  in  this  respect 
appears  to  be  the  rule,  success  the  rare  exception.^     I  think,  too, 

'  Professor  Scanzoni,  in  a  note  at  vol.  i,  p.  205,  of  the  fourth  edition  of  Kiwisch's 
■work  on  Diseases  of  Women,  and  at  p.  124  of  his  own  Lehrbuch  der  Kranhlieiten  der 
weibUchen  Sexualorgane,  8vo.,  Wien,  1857,  makes  some  remarks  on  this  subject, 
based  on  his  own  experience  at  Prague,  which  amply  bear  out  the  statements  in 
the  text,  and  corroborate  the  verdict  that  I  have  quoted  from  Professor  Kilian. 
He  says  that  of  five  cases  in  which  the  orifice  of  the  vulva  was  contracted  by  opera- 
tion, all  were  unsuccessful,  either  failing  from  the  first  to  retain  the  womb,  or  the 
newly-formed  perineum  stretching  by  degrees  till  at  length  the  orifice  of  the  vulva 
widened  so  as  to  allow  the  womb  to  protrude  just  as  it  had  done  before  the  opera- 
tion was  undertaken.  The  result  of  thirteen  cases,  in  which  it  was  endeavored  to 
produce  contraction  of  the  vagina,  was  still  more  unsatisfactory,  since  in  every  one 


OF    PROLAPSUS.  157 

that  if  we  consider  the  circumstances  in  which  prolapsus  either  of 
the  uterus,  rectum,  or  bladder  takes  place,  we  can  scarcely  expect 
that  the  result  of  the  operation  should  be  other  than  temporary  ; 
that  the  cicatrix  tissues  should  yield  to  the  pressure  from  above, 
and  that  all  their  other  causes  remaining  unremoved,  misplace- 
ment of  the  organs  should  in  most  instances  recur. 

The  operations  already  referred  to  seemed  to  deserve  rejection 
rather  on  account  of  their  inadequacy  to  effect  a  permanent  cure 
of  the  evils  for  the  removal  of  which  they  have  been  suggested, 
than  on  account  of  great  difficulties  or  great  danger  in  their  per- 
formance. The  removal  of  a  large  portion  of  the  neck  of  the 
womb,  however,  as  recommended  byAI.  ITuguier,  merits  condem- 
nation on  different  and  more  serious  grounds.  The  excision  of  the 
portio  vaginalis  of  the  uterus,  which  M.  Huguier  employs  in  some 
cases  of  descent  of  the  organ,  is  an  operation,  as  I  have  already 
stated,  by  no  means  free  from  danger,  and  additional  experience 
does  but  confirm  surgeons  in  their  view  of  it,  as  a  proceeding  not  to 
be  lightly  had  recourse  to.'  M.  Iluguier's  special  operation,  how- 
ever adapted,  as  he  believes,  to  cases  of  elongation  of  the  neck  of  the 
womb  above  its  connection  with  the  vagina,  is  of  a  far  more  for- 
midable kind,  and  "  consists  in  taking  away,  together  with  the 
upper  extremity  of  the  vagina,  the  whole  length  of  the  neck,  and, 
if  necessary,  the  lower  part  of  the  body  of  the  uterus,  removing  it 
by  an  incision  slanting  from  without  inwards,  after  having  pre- 
viously detached  the  bladder  from  the  part  to  be  excised."^  This 
statement  of  the  nature  of  the  operation  loses  nothing  of  its  for- 
midable character  if  one  reads  the  details  of  its  mode  of  perform- 
ance, or  looks  at  the  illustrative  plates,  or  considers  the  very  need- 
ful cautions  given  by  M.  Huguier  as  to  the  means  by  which  one 
may  best  avoid  opening  the  peritoneal  pouch  behind  and  the 

the  uterus  within  a  few  weeks  protruded  as  much  as  ever.  It  is  almost  superfluous 
to  add  anytliing  further  in  condemnation  of  proceedings  which  are  falling  into  dis- 
use hy  their  own  inutility.  I  cannot,  however,  refrain  from  adding  the  ojiinion  of 
Dr.  Gustav  Simon,  of  Darmstadt,  no  mean  authority  in  all  questions  of  this  kind. 
Monaischr.  f.  Geburisk^  1859,  vol.  xiii,  p.  284.  After  relating  an  unsuccessful  case 
on  which  he  himself  operated,  he  adds  that  he  has  frequently  watched  its  perform- 
ance by  other  surgeons,  and  believes  a  permanent  cure  of  prolapsus  to  be  very  rarely 
brought  about.  "  These  slender  results  of  episiorraphy,"  says  he,  "an  operation 
which  moreover  is  not  unattended  by  danger,  led  to  other  means  being  devised  for 
the  relief  of  prolapsus.  Recently,  indeed,  such  well-contrived  pessaries  have  been 
invented  (those  of  Rosen  and  Scanzoni,  of  Zwanck  and  Eul(>nberg)  that  it  can  very 
seldom  happen  for  a  case  to  occur  in  which  the  far  more  uncertain  and  more  hazard- 
ous operation  is  indicated.  In  not  a  single  one  indeed  of  the  rather  numerous  in- 
stances of  uterine  prolapse  which  have  come  under  mj"^  care,  since  the  performance 
of  the  operation  which  I  have  related,  have  I  found  it  necessary  to  resort  to  episi- 
orraphy, f(jr  in  every  one  suitable  pessaries,  generally  that  of  Zwanck,  retained  the 
prolapsus  just  as  well  as  the  most  successful  operation  could  have  done."  I  may 
add,  that  during  the  last  three  years  of  my  connection  with  !St.  IJartliolomew's 
Hospital,  I  did  not  meet  with  a  single  case  of  prolapsus  which  a  Zwanck's  pessary 
faih'd  to  retain. 

1  See  some  recent  cases  referred  to  in  the  discussion  on  M.  Huguier's  paper,  by 
M.  l)ej)aul.  Bulletin  de  I'Academie,  vol.  xxiv,  p.  682. 

2  Ojj.  cii.  p.  150. 


158    OPERATIONS  FOR  THE  CURE  OF  PROLAPSUS. 

bladder  in  front,  while  the  hemorrhage,  always  profuse,  can 
scarcely  fail  in  some  instances,  to  endanger  life. 

Moreover,  the  very  conditions  in  which  the  need  of  relief  is  most 
urgent,  are  those  which,  according  to  M.  Huguier,  forbid  the  per- 
formance of  the  operation,  inasmuch  as  he  says,  that  "a  capacious 
pelvis  and  a  large  opening  of  the  vulva,  more  or  less  laceration  of 
the  perineum,  and  considerable  relaxation  of  the  soft  parts  at  the 
pelvic  floor,  absolutely  contraindicate  it."^  I  would  confidently 
ask,  how  many  are  the  patients  suffering  seriously  from  the  symp- 
toms of  uterine  prolapse,  in  whom  some  one  or  more  of  these 
conditions  are  not  present,  and  in  what  persons  but  those  whose 
sufie rings  are  most  severe,  should  we  be  justified  in  setting  their 
life  upon  the  cast  by  the  performance  of  an  operation  which  rests 
on  a  false  hypothesis,  which  is  not  proved  to  be  permanent  in  its 
results  in  many  of  the  cases  where  it  has  been  performed,  and 
which  can  be  but  moderately  perilous  only  in  the  hands  of  those 
who  maybe  possessed  of  the  exceptional  dexterity  of  M.  Huguier?^ 

The  annals  of  medicine  contain  the  history  of  some  few  extra- 
ordinary cases  in  which  the  uterus,  having  long  been  procident, 
being  quite  irreducible,  and  having  been  attacked  by  inflammation 
which  terminated  in  gangrene,  has  been  removed  with  no  ill  effect 
by  means  of  the  ligature  and  knife.  I  have  no  personal  experience 
of  such  cases,  though  a  patient  was  once  sent  to  me  at  St.  Bar- 
tholomew's Hospital  to  have  the  procident  uterus  extirpated.  The 
procidentia,  however,  was  not  irreducible  ;  the  uterus  was  not  the 
seat  of  any  dangerous  inflammation,  and  the  woman  within  the 
previous  year  had  given  birth  to  a  child.  I  need  not  say  that  the 
operation  was  not  performed,  but  the  womb,  being  replaced  within 
the  pelvis,  was  retained  there  by  means  of  an  Ashburner's  band- 
age, and  the  patient. was  sent  back  to  the  country  in  a  state  of 
comparative  comfort. 

I  do  not  know,  however,  but  that  instances  may  occur  justify- 
ing this  proceeding,  and  further,  would  remind  you  that  the  womb, 
when  long  misplaced,  loses  much  of  that  sensibility  which  char- 
acterizes it  when  in  its  natural  position.  The  inverted  womb  has 
on  many  occasions  been  safely  removed  by  ligature,  and  one  of 
the  few  instances  of  successful  extirpation  of  the  cancerous  uterus 
was  that  recorded  by  the  younger  Langenbeck,  in  which  his  father 
performed  the  operation  on  a  womb  that  for  years  had  been  proci- 
dent beyond  the  external  parts.^ 

There  would  be  two  great  risks  to  be  avoided  in  such  a  proceed- 
ing :  the  one  would  be  that  of  opening  the  peritoneum,  the  other 
that  of  wounding  the  bladder,  which  viscus  in  almost  all  cases  of 

1  Ibid.,Y>.  166. 

2  The  criticisms  of  M.  Depaul  in  the  discussion  at  the  Academy  of  Medicine, 
those  already  referred  to  by  Scanzoni  in  vol.  iv  of  his  Beitrdge  on  this  and  the 
analogous  operation  of  Professor  Braun,  of  Vienna,  and  in  the  3d  edition  of  his 
LehTbnch,  published  in  1863,  pp.  143-147,  may  be  consulted  by  any  one  who  is 
desirous  to  pursue  this  subject  further. 

3  De  totius  uteri  exiirpatlone,  auctore  M.  Langenbeck,  4to.,  Gottingse,  1842. 


RETROVERSION    OF    THE    UNIMPREGNATED    "WOMB.         159 

considerable  or  long-standing  prolapse,  descends  far  down  in  tlie 
front  of  the  tumor,  and  without  much  care  would  be  very  likely 
to  be  injured. 


LECTURE   XI. 

MISPLACEMENTS  OF  THE  UTEKUS. 

Versions  and  Flexions  of  the  Uterus. 

Ketroversion  of  the  Womb ;  knowledge  of  its  existence  in  unimpregnated  state 
comparatively  recent.  Its  causes,  and  mode  of  its  occurrence.  Illustrative 
cases. 

Anteversion  often  confounded  with  anteflexion. 

Flexions  or  Uterus — probably  more  frequent  than  misplacements  of  whole 
organ — always  take  place  at  one  point,  and  why ;  comparative  frequency  of 
ante  and  retroflexion.  Absence  of  disposition  to  spontaneous  cure;  existence 
of  adhesions  and  of  atrophy  of  uterine  wall.  Influence  of  flexions  on  uterus 
in  other  respects,  hypertrophy  of  womb;  constriction  of  internal  os,  «&c. 

Obliquity  fi-om  congenital  malformation. 

"When  speaking  about  prolapsus  uteri,  I  explained  to  you  how 
it  occurs  that  descent  of  the  womb  is  always  associated  with  a  dis- 
position to  retroversion  of  the  organ;  or,  in  other  words,  to  a  fall- 
ing back  of  its  fundus  into  the  hollow  of  the  sacrum.  Such  minor 
degrees  of  retroversion,  however,  are  of  comparatively  trivial  im- 
portance, and  whatever  symptoms  they  may  occasion  are  entirely 
lost  in  the  general  consequences  of  the  downward  displacement 
of  the  womb. 

Cases,  however,  especially  of  late  years,  have  engaged  the  atten- 
tion of  practitioners,  in  which,  though  the  womb  may  be  some- 
what lower  than  natural,  yet  it  is  not  only,  nor  even  principally,  to 
this  displacement  that  the  patient's  symptoms  are  due,  but  rather 
to  a  falling  of  the  fundus  uteri  downwards  and  backwards  into  the 
hollow  of  the  sacrum,  accompanied  with  a  corresponding  elevation 
of  its  cervix,  which  is  directed  upwards  and  forwards  against  the 
symphysis.  To  Dr.  William  Hunter  we  owe,  if  not  the  first  men- 
tion, at  least  the  first  clear  description  of  this  retroversion  of  the 
womb  as  an  accident  liable  to  happen  in  the  early  months  of  preg- 
nancy;  and  since  his  time  no  treatise  on  midwifery  has  failed  to 
mention  its  occurrence,  and  to  delineate  its  symptoms  in  colors 
even  darker  than  are  always  needful. 

But  though  it  would  seem  natural  to  anticipate  that  this  acci- 
dent should  not  always  be  limited  to  the  pregnant  state,  but  might 
also  sometimes  hap})en  in  any  other  circumstances  which  rendered 
the  womb  heavier  than  natural,  and  its  supports  more  lax,  yet  it 
was  long  before  this  was  recognized  as  a  general  fact,  and  the  few 
instances  of  the  displacement  which  were  from  time  to  time  re- 
corded by  continental  writers  were  regarded  as  rare  and  excep- 
tional occurrences.  The  minute  detail  of  four  cases  of  this  mis- 
placement of  the  unimpregnated  womb,  by  Professor  Osiauder,  of 


160  CAUSES    OF 

Gbttingen,  in  the  year  1808,  then  in  the  zenith  of  his  reputation, 
did  much  towards  directing  attention  to  the  subject.  It  was  not, 
however,  until  some  years  later  that  the  publication  of  the  essays  of 
Professor  Schweighauser,^  of  Strasburg,  and  of  Professor  Schmitt, 
of  Vienna,Mully  established  the  frequency  of  the  accident,  and 
furnished  a  description  of  its  symptoms  so  minutely  accurate  as  to 
have  left  little  room  for  the  additions  of  subsequent  observers. 

The  researches  of  these  German  writers  attracted  but  little  atten- 
tion out  of  their  own  country;  and  retroversion  of  the  womb,  as 
well  as  the  opposite  condition  of  its  anteversion,  were  regarded 
by  medical  writers,  both  in  France^  and  England,  as  ailments  ex- 
tremely unusual  in  the  unimpregnated  condition  of  the  womb. 
In  the  year  1848,  however,  a  paper  was  published  in  the  Dublin 
Journal  of  Medical  Sciences,  by  Professor  Simpson  of  Edinburgh, 
on  retroversion  and  other  misplacements  of  the  unimpregnated 
womb — accidents  to  which  he  had  already  drawn  attention  five 
years  before  at  a  meeting  of  the  Medico-Chirurgical  Societj^  of 
Edinburgh;  and  since  that  time  the  danger  has  been  lest  the  im- 
portance and  frequency  of  these  conditions  should  be  overrated, 
rather  than  lest  they  should  be  underestimated.^ 

One  of  the  results  of  close  attention  being  directed  to  the  situa- 
tion of  the  womb  in  the  pelvic  cavity,  has  been  to  show  that  the 
organ  is  liable  in  this  respect  to  very  great  varieties  ;  that  not 
only  may  its  fundus  fall  backwards  into  the  hollow  of  the  sacrum, 
or  forwards  against  the  symphysis  pubis,  but  that  it  may  also  in- 
cline towards  either  side  ;  and  that  moreover  its  body  is  liable  to 
be  bent  upon  the  cervix,  constituting  a  new  class  of  misplacements 
called  flexions.  There  seems  also  to  be  reason  for  believing  that 
the  difteront  varieties  of  flexions  of  the  womb,  as  its  retrojiexion 
and  antejlexion,  are  of  more  frequent  occurrence  than  the  corre- 
sponding alterations  in  position  of  the  whole  of  the  organ  which 
are  known  as  retroversion  and  anteversion. 

Fewer  difiiculties  present  themselves  in  the  way  of  understand- 
ing the  mode  of  occurrence  of  retroversion  than  of  the  other  above- 
mentioned  misplacements  of  the  womb.  It  has  already  been  seen 
that  the  tendency  of  the  womb,  when  at  all  enlarged,  is  not  only 
to  sink  below  its  natural  position  in  the  pelvic  cavity,  but  at  the 
same  time  to  fall  with  its  fundus  backwards  towards  the  hollow 

1  Schweighauser,  Aufsdtze  uher  einige  Ger/enstdnde  der  GehurtshuJfe,  8vo.,  Niirn- 
berg,  1817,  cap.  xxviii,  p.  251;  and  Das  Gebdren  nach  der  beobachteten  Natur, 
Strasburg,  1825,  8vo.,  p.  234. 

2  Bemerkungen  iiber  Zuriickbeugung  der  Gebdrmutier  bei  Nichtschwangeren,  8vo., 
Wien,  1820. 

3  From  this  statement,  however,  it  is  only  just  to  except  the  name  of  M.  Velpeau, 
who  was  led  by  his  own  observation  long  since  to  appreciate  the  frequency  and 
importance  of  flexions  of  the  uterus,  and  to  devise  means  for  their  cure.  See  p.  14 
of  a  small  tract  of  his.  Maladies  de  I' Utertts,  8vo.,  Paris,  1854. 

*  Opinions  at  variance  with  those  of  Dr.  Simpson  were  however  expressed  by 
several  writers,  as,  for  instance,  by  Dr.  Bennett,  Dr.  Oldham,  and  Dr.  Matthews 
Duncan,  of  Edinburgh,  who,  though  difl'ering  from  each  other  in  some  respects, 
yet  all  formed  a  low  estimate  of  the  importance  of  mere  versions  or  flexions  of  the 
uterus,  and  dissented  from  the  employment  of  mechanical  means  for  their  removal. 


RETROVEESrON     OF    THE    WOMB.  161 

of  the  sacrum,  in  consequence  of  the  utero-sacral  ligaments  con- 
fining it  more  closely  to  the  posterior  part  of  the  pelvis  than  do 
the  utero-vesical  ligaments  to  the  anterior  pelvic  wall.  Aloreover, 
enlargement  of  the  womb,  whether  from  the  presence  of  fibrous 
tumor,  or  dependent  on  simple  congestion  and  consequent  liyper- 
trophy  of  the  organ,  or  resulting  from  its  imperfect  involution 
after  delivery  or  miscarriage,  is  almost  alwaj's  much  more  con- 
siderable at  its  posterior  than  at  its  anterior  wall,  and  the  womb 
in  consequence  naturally  falls  towards  that  side  which  is  the 
heavier.  The  ordinary  distension  of  the  bladder,  too,  necessarily 
tends  to  throw  the  uterus  into  the  posterior  half  of  the  pelvis ; 
and  if  the  utero-vesical  ligaments  be  at  all  yielding,  as  they  must 
be  in  cases  where  some  degree  of  prolapsus  exists,  the  same  cause 
must  also  dispose  the  fundus  of  the  organ  to  fall  backwards;  while 
the  inclination  to  the  malposition  will  be  increased  by  a  loaded 
state  of  the  bowels  such  as  exists  habitually  in  many  persons. 

When  favoring  causes  such  as  have  been  just  referred  to  coin- 
cide, retroversion  of  the  womb  may  take  place  either  gradually, 
or  as  the  result  of  some  sudden  accident  which  violently  increases 
the  uterine  misplacement,  and  throws  the  fundus  of  the  organ 
downwards  and  backwards  into  the  hollow  of  the  sacrum.  It  is 
thus  suddenly  that  in  the  majority  of  instances  retroversion  of  the 
pregnant  womb  takes  place — an  accident,  the  comparative  rarity 
of  which  is,  I  apprehend,  to  be  accounted  for  mainly  by  the  cir- 
cumstance that  not  only  does  its  physiological  enlargement  equally 
extend  to  the  whole  of  the  organ,  but  also  that  the  size  and  strength 
of  its  ligaments  increase  with  the  added  weight  which  they  have  to 
bear.  But  while,  owing  to  this  wise  provision,  the  pregnant  womb 
rises  gradually  and  safely  out  of  the  pelvic  cavity,  the  hypertro- 
phied  organ,  or  that  whose  involution  is  imperfect,  or  in  whose 
substance  tumors  are  developed,  being  destitute  of  such  duly  in- 
creased supports,  sinks  down  far  lower  than  natural  in  the  pelvis. 

The  sudden  eftbrt  and  consequent  violent  misplacement  which 
we  generally  find  to  constitute  the  history  of  retroversion  of  the 
enlarged  and  pregnant  womb,  are  sometimes  equally  marked  in 
the  case  of  the  non-gravid  uterus,  showing  that  the  mode  of  oc- 
currence of  the  accident  is  identical  in  both  instances.  Thus,  a 
woman  aged  thirty,  whose  second  and  last  labor  had  taken  place 
sixteen  months  before,  while  reaching  over  the  fire  to  remove  a 
heavy  tea-kettle,  was  suddenly  seized  by  violent  pain  referred  to 
the  back  and  the  umbilicus,  and  became  for  a  time  unable  to  pass 
her  urine,  and  thougli  she  afterwards  voided  it,  yet  it  was  with 
pain  and  difiiculty,  and  defecation  also  was  attended  by  pain.  On 
examination  per  vaginam  the  finger  came  in  contact  with  a  firm, 
but  slightly  elastic,  globular  tumor,  which  felt  about  half  the  size 
of  an  orange,  and  occu[)iod  the  posterior  half  of  the  pelvis,  having 
driven  before  it  the  posterior  vaginal  wall,  while  the  rectum  could 
be  traced  |)assing  behind  it.  The  situation  of  this  tumor  was  not 
exactly  in  the  mesial  line,  but  it  occupied  rather  more  of  the  right 
than  of  the  left  half  of  the  pelvis,  while  the  os  uteri  was  situated. 

11 


162  CAUSES    OF 

high  up,  immediately  behind  the  symph^'sis  pubis,  but  a  little  to 
the  left  of  the  mesial  line.  I  may  remark,  in  passing,  that  to  this 
slight  obliquit}^  of  the  retroverted  uterus  it  is  due  that  the  urethra 
and  neck  of  the  bladder  not  infrequently  escape  that  pressure 
which  would  otherwise  be  unavoidable ;  and  thus  it  happens  that 
difficulty  of  micturition  is,  in  many  instances  even  of  retroversion 
during  pregnancy,  by  no  means  so  prominent  a  symptom  as  the 
statements  in  most  systematic  treatises  on  the  diseases  of  women 
might  lead  one  to  expect.  There  was,  besides,  in  the  left  iliac 
region,  a  firm  slightly  movable  tumor,  whose  surface  was  a  little 
irregular,  as  if  nodulated,  and  pressure  upon  it  was  communicated 
to  the  tumor  in  the  pelvis.  Inquiry  ascertaining  that  the  patient's 
bowels  had  long  been  in  a  constipated  condition,  it  was  assumed 
that  while  the  sudden  exertion  had  retroverted  the  uterus,  the 
accumulation  of  fpeces  in  the  sigmoid  flexure  oY  the  colon  and  in 
the  upper  part  of  the  rectum  had  prevented  its  spontaneous  re- 
placement. Enemata  and  purgatives  were  employed,  and  in  the 
course  of  seven  days  the  womb,  which  was  not  much  larger  than 
natural,  had  completely  regained  its  proper  position,  while  a  vague 
sense  of  some  swelling  in  the  posterior  part  of  the  pelvis  was  as- 
certained to  be  due  merely  to  the  existence  of  very  great  hyper- 
trojihy  of  the  walls  of  the  rectum,  a  condition  which  is  by  no  means 
uncommon  in  cases  of  long-standing  habitual  constipation. 

It  is  not  thus  suddenly,  however,  that  retroversion  of  the  unim- 
pregnated  uterus  usually  occurs.  In  th(^ majority  of  instances  the 
accident  may  be  traced  back  to  labor,  menstruation,  or  miscarriage ; 
to  some  condition,  in  short,  which  combines  considerable  enlarge- 
ment of  the  womb  with  weakening  of  its  supports.  A  patient  was 
received  into  St.  Bartholomew's  Hospital,  on  account  of  what  was 
alleged  to  be  a  tumor  in  her  womb,  and  suflering  from  frequent 
hemorrhage,  from  pain  in  the  sacrum  and  hypogastrium,  and  from 
painful  and  difficult  defecation.  All  these  symptoms  dated  from 
a  miscarriage  at  the  third  month,  which  had  occurred  six  weeks 
before.  The  uterus  was  completely  retroverted,  the  os  being  di- 
rected forwards  and  somewhat  upwards,  while  an  elastic,  globular, 
slightly  tender  tumor  occupied  the  hollow  of  the  sacrum.  The 
uterine  sound  entered  for  five  inches  and  three-quarters,  with  its 
concavity  directed  backwards,  and  on  turning  the  instrument 
round,  the  tumor  completely  disappeared.  Rest  was  followed  by 
cessation  of  the  hemorrhage,  the  use  of  the  cold  douche  led  to 
some  diminution  in  the  size  of  the  uterus,  though  it  was  still  as 
much  retroverted  as  ever,  when  the  outbreak  of  small-pox  in  the 
ward  compelled  the  patient's  discharge  from  the  hospital  in  less 
than  three  weeks  after  her  admission. 

Just  two  years  later,  the  patient  came  once  more  under  my 
notice.  She  had  in  the  interval  been  pregnant  several  times,  but 
had  on  each  occasion  miscarried  early,  while,  when  not  pregnant, 
she  had  suffered  much  from  menorrhagia.  The  uterus  was  no 
longer  so  enlarged  as  before,  though  of  greater  size  than  natural, 
but  its  misplacement  was  just  as  considerable ;  still,  however,  ad- 


RETROVERSION    OF    THE    WOMB.  163 

mitting  of  momentary  removal  by  means  of  the  sound,  but  almost 
immediately  falling  back  into  its  former  position.  If  this  person 
had  not  been  exposed  to  the  risks  of  becoming  pregnant,  there 
can  be  no  doubt  but  that  the  involution  of  lier  womb  would  have 
taken  place  much  more  completely;  though  even  then  the  mis- 
placement would  almost  certainly  have  continued  unrelieved,  and 
accident  might  then  have  discovered  a  small  and  otherwise  healthy 
uterus  completely  retroverted,  with  no  other  clue  to  the  cause  of 
this  occurrence  than  would  have  been  furnished  by  the  history  of 
a  miscarriage,  succeeded  by  long-continued  hemorrhage  some 
years  before. 

The  state  of  the  womb  during  menstruation  is  similar  to  its  con- 
dition after  miscarriage,  and  favors  in  the  same  manner,  though 
of  course  in  a  less  degree,  the  descent  of  the  organ  or  its  retrover- 
sion, while  in  every  form  of  misplacement  of  the  uterus  the  ten- 
dency of  things  is  to  a  deterioration  rather  than  to  an  improvement. 
The  accumulation  of  urine  in  the  bladder,  the  distension  of  the 
rectum  with  fseces,  have  a  disposition  to  aggravate  the  misplace- 
ment, while  the  stretched  ligaments  and  the  lax  vagina  have  no 
power  of  spontaneously  recovering  their  tone,  and  of  thereby  favor- 
ing the  replacement  of  the  womb.  With  the  return  of  each  men- 
strual period,  too,  the  uterus  for  the  time  grows  heavier,  and 
subsides  further  and  still  further  back  in  the  pelvis,  till  at  length 
its  retroversion  becomes  complete.  Nor  must  it  be  forgotten  that 
in  some  at  least  of  the  instances  of  this  and  of  kindred  misplace- 
ments, any  permanent  improvement  is  effectually  prevented  by 
the  formation  of  adhesions  between  the  fundus  of  the  uterus  and 
the  surface  of  the  adjacent  intestines.  Such  attacks  of  circum- 
scribed peritonitis  as  to  produce  these  consequences  were  first 
noticed  by  Madame  Boivin'  as  a  cause  of  abortion,  and  she  appears, 
indeed,  to  have  exaggerated  both  their  frequency  and  their  import- 
ance. They  are,  nevertheless,  of  considerable  moment,  and  none 
the  less  for  the  circumstance  that  they  are  by  no  means  constantly 
accompanied  by  symptoms  so  severe  as  to  force  themselves  on  the 
patient's  attention.  Their  occurrence,  and  the  consequences  which 
they  leave  behind,  sufficiently  account  for  the  immobility  of  the 
retroverted  uterus  in  some  instances,  for  its  difficult  replacement 
and  immediate  resumption  of  its  malposition  in  others. 

Although  I  have  spoken  first  of  retroversion  of  the  w^omb,  yet 
the  opposite  state  oi anteversion  of  the  unimpregnated  organ  earlier 
attracted  attention,  and  was  described  by  Levret'  with  character- 
istic accuracy.  In  this  condition  the  fundus  is  directed  forwards 
against  the  symphysis  of  the  pubes,  and  its  orifice  backwards  into 
the  hollow  of  the  sacrum.  How  this  accident  comes  to  hapjien, 
and  to  happen  even  with  considerable  frequency,  is  certainly  not 
easy  to  understand.     The  very  form  of  the  pelvis,  as  observed  by 

1  Rec.herc.hen  nnr  une  des  causes  les  plus  frequentes,  et  la  moins  coniiue  de  I'Avoi-te- 
,neni,  8vo.,  Pnris,  1822. 

^  "8iir  un  deplaconiont  particulior  do  la  matrice,  dont  los  autcurs  n'ont  point 
parle,"  in  lioux,  Journal  de  Medecine,  etc.,  Sept.  1773,  vol.  xl,  p.  209. 


164  ANTEVBRSION 

the  late  Professor  Kiwisch/ while  it  favors  the  production  of  retro- 
version, is  opposed  to  any  such  misplacement  as  the  anteversion 
of  the  womb,  while  the  accumulation,  of  the  urine  in  the  bladder 
and  of  the  fseces  in  the  rectum,  the  former  takino;  place  from  below 
upwards,  the  latter  from  above  downwards,  alike  tend  to  prevent 
and  remove  it.  There  is,  besides,  no  such  pouch  of  peritoneum 
in  front  of  the  uterus  as  exists  behind  it,  allowing  space  for  the 
descent  of  the  fundus  uteri,  and  for  its  residence  in  this  unnatural 
situation.  In  spite,  however,  of  these  conditions,  which  would 
seem  to  oppose  the  occurrence  of  anteversion  of  the  uterus,  it  is 
yet  met  with  in  many  instances,  though  I  believe  less  often  un- 
associated  with  previous  enlargement  of  the  organ  than  the  oppo- 
site state  of  retroversion.  Thus  in  fourteen  out  of  twenty  cases 
of  anteversion  or  anteflexion  of  the  womb  there  was  marked  en- 
largement of  the  organ,  while  the  history  of  the  patients  further 
warranted  the  belief  that  the  misplacement  was  in  these  instances 
secondary  to  other  much  longer  standing  diseases.  Such  I  believe 
to  have  been  the  cause  of  the  misplacement  of  the  womb  in  a 
patient  whom  I  saw  four  years  after  her  delivery,  which  had  been 
succeeded  by  phlegmasia  dolcns,  and  symptoms  of  uterine  inflam- 
mation so  severe  as  to  have  confined  her  to  her  bed  for  three  months. 
Such  possibly  was  tlie  real  history  of  a  woman  who  had  lived  three 
years  in  sterile  marriage,  and  who  was  attacked  suddenly  during 
menstruation,  ten  months  before  I  saw  her,  by  severe  pains  in  the 
abdomen,  followed  by  temporarj^  cessation  of  the  menses,  by  great 
pain  in  the  hypogastrium,  difficulty  and  pain  in  micturition,  and 
symptoms  like  those  of  severe  vaginitis,  and  who  had  ever  after 
experienced  attacks  of  violent  parox3'smal  uterine  pain.  Her 
uterus  was  both  hard  and  enlarged,  the  fundus  resting  against 
the  symphysis,  and  the  os  in  the  hollow  of  the  sacrum.  Some- 
times, moreover,  one  meets  with  an  increased  degree  of  obliquity 
of  the  womb,  though  short  of  actual  anteversion,  which  appears 
to  be  the  almost  mechanical  result  of  sexual  intercourse.  When 
in  connection  with  this  exaggerated  obliquity  of  the  womb,  there 
has  also  existed  some  congestion  of  the  organ,  such  as  is  not  un- 
usual, particularly  in  sterile  women,  the  misplacement  is  then 
often  associated  with  symptoms  of  uterine  disorder,  which  prob- 
ably are  due  less  to  it  than  to  the  gorged  state  of  the  bloodvessels 
with  which  it  is  associated. 

Still  there  are  instances,  though  of  far  less  frequency  than  those 
above  referred  to,  in  which  there  is  no  evidence  of  previously 
existing  disease,  but  where  the  anteversion  of  the  womb  was 
apparently  a  primary  occurrence.  It  was  so  in  the  remarkable 
case  which  first  drew  the  attention  of  Levret'  to  this  malposition. 
In  this  instance,  the  fundus  of  the  anteverted  womb  was  taken  for 
a  calculus  in  the  bladder,  and  the  patient  died  from  the  effects  of 
lithotomy  performed  under  this  erroneous  idea.  In  this  instance, 
it  is  expressly  stated  that  slight  engorgement  of  the  anterior  wall 

1  Op.  cit,  vol.  i,  p.  235.  2  l^^c.  cit,  p.  269. 


OF    THE    WOMB.  105 

of  tlie  uterus,  and  a  somewliat  unusual  shortness  of  the  round 
ligaments,  were  the  only  appreciable  causes  of  its  malposition. 
A  woman,  aged  thirty,  the  mother  of  four  children,  the  last  of 
whom  was  born  three  3'ears  before  she  came  under  my  observa- 
tion, had  ever  since  experienced  some,  though  inconsiderable, 
abdominal  pain.  A  few  days  before  I  saw  her,  however,  while 
turning  a  mangle,  she  felt  a  sudden  pain  over  the  pubes,  which 
extended  over  the  whole  pelvic  region,  and  on  making  an  exami- 
nation,  the  uterus  was  found  remarkably  anteverted,  the  os  being 
in  contact  with  the  anterior  wall  of  the  sacrum,  and  the  fundus 
resting  against  the  inner  surface  of  the  sympliysis.  It  seems  diffi- 
cult here  to  avoid  connecting  the  symptoms  suddenly  supervening 
during  exertion  with  the  misplacement  of  the  womb.  Still  harder 
does  it  appear  to  me  to  be  able  to  account  for  the  malposition  of 
the  organ  in  an  unmarried  ladj'^,  aged  thirty-four,  whose  menstrua- 
tion had  been  habitually  scanty,  and  who  had  suiFered  for  eight 
months  before  she  came  under  my  care  fi'om  hemorrhoids,  ac- 
companied by  profuse  loss  of  blood.  For  four  months  she  had 
also  experienced  abiding  aching  pain  in  the  hypogastrium,  with 
frequent  and  painful  micturition.  Her  uterus  was  lying  almost 
horizontally  across  the  pelvis,  its  orifice  being  directed  backwards, 
and  to  the  left,  and  this  to  so  great  a  degree  as  to  render  it  almost 
impossible  to  touch  the  small  circular  os,  while  the  fundus  was 
situated  in  the  .same  manner  forwards  and  to  the  right. 
.  Be  the  explanation  of  cases  such  as  the  above  what  it  may, — and 
I  confess  myself  unable  satisfactorily  to  solve  all  the  difficulties 
which  they  present, — there  can  be  no  doubt  but  that,  in  the  greater 
number  of  instances  of  alleged  version  of  the  womb  either  forwards 
or  backwards,  the  organ  is  really  flexed,  or  bent  upon  itself;  and 
further,  that  not  infrequently  the  two  conditions  coexist,  the 
whole  womb  being  thrown  more  forwards  or  more  backwards 
than  natural,  while,  in  addition,  the  body  of  the  organ  is  bent  upon 
its  cervix.  As  far  as  the  symptoms  are  concerned  to  which  they 
give  rise,  these  varieties  of  misplacement  present  but  little  differ- 
ence; but  the  distinction  deserves  to  be  borne  in  mind,  since  it 
throws  light  on  the  manner  in  which  the  accident  is  in  many  in- 
stances brought  about. 

The  point  of  flexion  of  the  uterus,  whether  it  is  bent  forwards  or 
backwards,  appears  always  to  be  the  same — namely,  the  point 
of  junction  between  the  body  and  neck  of  the  womb,  or,  in  other 
words,  a  spot  corresponding  to  the  intorual  os  uteri;  so  that  the 
organ  assumes  a  shape  closely  resembling  that  of  a  chemical  re- 
tort. Various  reasons  have  been  assigned  for  the  constancy  with 
which  the  organ  is  found  to  bend  at  this  one  situation  ;  and  various 
theories,  such  as  an  assumed  atrophy  of  one  part  of  the  uterine 
walls  and  engorgement  of  its  fundus  while  the  cervix  remains  un- 
altered, and  other  suggestions  less  plausible,  have  been  ])roposcd 
in  explanation  of  the  fact.  But  these  conditions  arc  by  no  means 
invariably  present  even  in  cases  of  most  marked  flexion  of  the 
womb,  and  must  therefore  be  rejected  as  inadequate  to  account 


166  FLEXIONS  OF  THE  UTERUS: 

for  its  taking  place  at  the  same  situation  in  all  cases.  The  only 
explanation  that  I  know,  against  which  no  such  objection  can  be 
raised,  is  that  propounded  by  Professor  Vircjhow,  of  Berlin,^  and 
which  is  based  on  the  anatomical  relations  of  the  organ.  He  points 
out  the  fact,  that  while  the  neck  of  the  womb  is  tirmly  connected 
with  the  posterior  and  lower  part  of  the  bladder,  its  body  is  per- 
fectly movable  ;  the  point  to  which  the  peritoneum  descends  in 
the  utero-vesical  pouch  corresponding  exactly  to  the  situation  of 
the  internal  os  uteri,  and,  consequently,  to  the  spot  where  the 
fixed  cervix  passes  over  into  the  movable  body  of  the  organ.  The 
posterior  surface  of  the  cervix  uteri,  though  somewhat  strength- 
ened by  the  cellular  tissue  which  surrounds  it,  is  by  no  means  so 
firmly  fastened  as  its  anterior  surface  ;  while  the  pouch  of  perito- 
neum descends  much  lower  down  behind  it,  and  is  even  on  a  lower 
level  than  the  summit  of  the  roof  of  the  vagina.  If,  now,  any  cause 
interfere  with  the  ready  mobility  of  the  l)ody  of  the  womb,  while 
the  attachments  of  its  cervix  retain  their  firmness  and  resistance, 
a  bending  of  the  one  part  on  the  other  must  of  necessity  take 
place  ;  a  bending  which  may  occur  either  forwards  or  backwards, 
find  thus  constitute  either  anteflexion  or  retroflexion.  With  refer- 
ence to  the  production  of  the  accident,  it  is  probably  a  matter  of 
indiftbrence  whether  its  cause  is  one  that  operates  gradually  and 
continuously,  or  suddenly  and  with  great  force — a  violent  exertion 
may  therefore  produce  it ;  and  just  as  much  may  the  slow  action 
of  adhesions  tethering  the  fundus  of  tlie  womb  either  to  the  blad- 
der or  the  rectum,  and  compelling  the  organ  in  the  course  of  time 
to  yield  at  its  weakest  point — namely,  at  that  which  corresponds 
to  the  junction  of  the  body  and  neck  of  the  organ. 

This  explanation  will  account  equally  for  the  occurrence  of 
anteflexion  and  of  retroflexion.  Of  the  two  misplacements,  the 
former  is  alleged  by  Rokitansky,  and  by  other  morbid  anatomists, 
to  be  the  more  frequent ;  and  observations  during  life  confirm,  on 
the  wliole,  the  correctness  of  this  statement.  In  my  own  notes, 
indeed,  I  find  the  particulars  of  forty-three  cases  of  retroversion 
or  retroflexion,  and  of  only  twenty  of  anteversion  or  anteflexion ; 
but  these  results  are  at  variance  with  those  of  some  most  trust- 
worthy observers,  and  I  believe  they  are  due  to  the  circumstance, 
that  in  the  early  period  of  my  observations  I  often  failed  to  mark 
the  slighter  degrees  of  anteflexion.  Valleix,  in  his  valuable  lec- 
tures on  this  subject,^  gives  thirty-five  deviations  of  the  uterus  for- 
wards, and  thirty-three  backwards ;  Dr.  ]Mayer,^  of  Berlin,  met 
with  sixty-three  cases  of  the  former,  and  sixty-four  of  the  latter ; 
and  MM.  Bernutz,  Goupil,  and  Gosselin  found  a  greater  or  less 
decrree  of  flexion  or  version  of  the  uterus  forward,  in  106  out  of 

1  Ueher  die  Knicknngen  der  GebdrrmiUer ;  in  the  Verhandlunyen  der  Gesellschaftfiir 
Gebu?-ts/nllfe,  vol.  iv,  1851,  p.  80. 

*  Des  Deviations  Vterines,  8vo.,  Paris,  1852,  see  p.  27. 

3  As  stated  by  Dr.  Eockwitz,  in  Verhandl.  der  Gesellschaftf.  Gehurtsh.,  vol.  v, 
1852,  see  p.  85. 


THEIR     MODE    OF    OCCURRENCE.  167 

163  women  who  had  never  given  birth  to  children.^  This  hitter 
statement,  however,  represents  the  frequency  of  tliat  physiological 
curvature  of  the  womb  which,  while  it  exists  in  the  child  and  in 
the  unmarried  womttn,  ceases  after  childbirth,  or  is  even  replaced 
by  a  disposition  to  version  or  flexion  of  the  fundus  backwards.  A 
condition  met  with  in  two  women  out  of  three  can  scarcely  be 
other  than  natural ;  and  while  I  may  have  often  overlooked  it,  I 
believe  that  I  do  not  err  in  regarding  it  as  usually  of  but  small 
importance. 

The  older  opinions  on  this  subject,  indeed,  are  in  conformity 
with  the  conclusions  which  I  have  arrived  at,  and  I  believe  them 
to  be  correct,  as  far  as  any  such  degree  of  misplacement  is  con- 
cerned, as  would  manifest  itself  by  sj'mptoms  during  life ;  while 
the  whole  subject  of  uterine  versions  and  flexions  lias  been  of  late 
much  obscured  by  the  confounding  together  of  the  natural  and  the 
morbid  degrees  of  these  misplacements.  There  can  be  no  doubt, 
indeed,  but  that  slight  degrees  of  anteflexion  of  the  uterus  are 
frequently  overlooked  during  life,  since  not  only  does  the  finger 
come  less  readily  into  contact  with  the  parts  in  the  anterior  than 
with  those  in  the  posterior  half  of  the  pelvis,  but  further,  unless 
the  bladder  be  completely  empty,  the  tumor  of  the  anteflexed  womb 
is  scarcely  perceptible.  A  slight  flexion  of  the  womb  forwards  is, 
however,  a  natural  condition,  as  is  exceedingly  well  shown  in 
Koldrausch's  beautiful  delineation  of  a  section  of  the  pelvic  viscera.^ 
"  The  uterine  canal,"  says  he,  "is  not  straight,  but  slightly  curved, 
like  an  italic  /,  and  the  whole  organ  has  in  its  natural  position  a 
slight  flexure,  being  curved  at  first  a  little  backwards,  then  bent 
more  considerably  forwards."  This  curve,  Ijiowever,  is  no  longer 
apparent  after  childbearing,  while,  besides,  any  cause  which  pro- 
duces enlargement  of  the  womb,  brings  with  it  those  influences 
that  tend  to  favor  retroversion  or  retroflexion  of  the  organ. 

The  explanation  that  has  been  proposed  of  the  invariable  occur- 
rence of  flexion  of  the  uterus  at  the  same  point,  suggests  the  reason 
why  the  ailment  has  no  tendency,  or  scarcely  any  tendency,  to 
spontaneous  cure,. and  explains  why  the  misplaced  womb  remains 
misplaced  for  years.  Two  conditions,  moreover,  tend  to  give  to 
the  misplacement  a  permanent  character,  of  which  one  is  the  pres- 

'  See  notes  3  and  4,  at  p.  465  of  vol.  ii  of  Bornutz  and  Goupil's  Clinique  Medi- 
cale  sw  les  Maladies  des  Femmes,  8vo.,  Paris,  18C2. 

-  Zur  Anatdniie,  etc.,  der  Bec.ke7inj-f/nne,  4to.,  Leipsig,  1854.  In  a  paper  read 
before  the  Medico-Chirurcical  Society,  and  afterwards  published  in  the  Dublin 
Medical  J<»t7-na.l,  August,  1857,  Dr.  Bennett  gave  the  results  of  his  own  investiga- 
tions on  the  living  subject,  which  led  to  precisely  the  same  conclusions  as  those 
arrived  at  by  Kohlrausch.  The  observations  of  Boullard,  contained  in  his  thesis, 
which  apjiearod  in  1853,  who  believed  that  a  degree  of  anteflexion  of  the  uterus, 
far  excci'ding  any  gentle  curve,  was  the  really  normal  state  of  the  uterus,  have 
been  sliown  by  Depaul  (Gazelle  des  Ilopitaux,  No.  36,  1854),  to  be  vitiated  by  the 
circumstances  in  wliich  they  were  made,  and  that  purely  cadaveric  causes  are 
chiefly  inHuential  in  producing  great  flexions  of  the  organ,  and  especially  flexions 
of  the  fundus  forwards.  Boullard's  statements,  however,  though  they  exaggerated 
the  degree  of  the  natural  curvature  were  correct  as  to  the  fact  of  its  general  exist- 
ence, and  deserve  the  praise  which  attaches  to  i>riority  of  observation. 


168  ANATOMICAL    RESULTS 

ence  of  adhesions  binding  down  the  fundus  of  the  uterus,  either 
to  the  rectum  posteriorly,  or  to  the  bhidder  in  front;  the  other  is 
the  wasting  of  that  wall  of  the  uterus  towards  which  the  flexion 
has  taken  place,  and  which  must  necessarily  render  the  organ  in- 
capable of  retaining  its  natural  position,  even  though  it  were  pos- 
sible to  replace  it  completely.  Of  these  two  conditions  the  former 
is,  I  believe,  the  more  frequent,  and  therefore  the  more  important. 
Such  adhesions  are  expressly  mentioned  in  many  of  the  cases 
where,  on  examination  after  death,  flexions  of  the  womb  have 
been  discovered,  and  I  can  speak  to  the  extreme  frequency  of 
adhesions,  false  membranes,  or  other  indications  of  bygone  in- 
flammation about  the  womb  or  its  appendages,  since  I  met  with 
them  in  twenty-two  out  of  sixty-six  cases  in  which  I  examined 
the  uteri  of  women  who  had  died  of  some  other  than  uterine  dis- 
ease. There  appears  to  be  some  uncertainty  as  to  the  date  of  the 
occurrence  of  atrophy  of  the  uterine  wall,  and  also  as  to  the  degree 
in  which  it  takes  place.  I  found  no  trace  of  it  in  a  case  where 
the  uterus  was  greatly  anteflected,  and  where  the  existence  of 
marked  uterine  symptoms  for  man}'  years  rendered  it  probable 
that  the  condition  was  of  long  standing;  and  it  is  expressly  stated 
by  Dr.  Kockwitz'  not  to  have  been  present  in  the  case  of  a  woman 
whose  uterus  had  been  completely  retroflected'for  a  year  by  the 
presence  of  an  ovarian  tumor.  On  the  other  hand,  Virchow  de- 
scribes the  gradual  wasting  of  the  muscular  substance  at  the  point 
of  flexion  till  nothing  is  left  but  a  small  quantity  of  flaccid,  slightly 
fibrous,  cellular  tissue;  and  in  a  very  useful  essay  on  the  subject, 
Dr.  Sommer  relates  some  post-mortem  examinations  in  which  this 
atrophy  of  the  uterine  wall  was  very  remarkable. 

The  eflcct  of  such  a  change  in  the  uterine  wall  is  twofold.  On 
the  one  hand  it  weakens  the  tissue  at  one  point,  and  thus  incapaci- 
tates the  organ  for  maintaining  its  proper  position  ;  on  the  other 
it  shortens  the  wall  towards  A\hich  the  flexion  exists,  and  thereby 
insures  still  more  eftectually  the  permanence  of  the  malposition  ; 
and  no  one  who  is  familiar  with  uterine  ailments,  and  has  felt  the 
bent  uterus  resume  its  malposition  immediately  on  the  removal  of 
the  sound  by  which  it  had  just  been  rectified,  but  must  believe 
that  such  wasting  of  one  uterine  wall  must  exist  in  a  very  large 
number  of  instances. 

A  frequent,  though  by  no  means  an  invariable  result  of  long- 
standing flexion  of  the  womb,  and  one  which  must  be  borne  in 
mind  as  explaining  some  of  the  symptoms  to  which  it  occasionally 
gives  rise,  is  a  contraction  of  the  internal  orifice  of  the  womb.  This 
constriction  too,  is,  at  any  rate  in  Virchow's  opinion,  not  a  merely 
mechanical  approximation  of  the  two  sides  of  the  canal  by  the 
bending  of  the  organ,  but  is  in  many  instances  due  to  an  organic 
narrowing  of  the  passage,  produced  by  the  constant  irritation  of 
the  mucous  membrane  at  this  spot,  and  its  consequent  thickening. 

1  Loc.  cit.,  p.  82. 

2  Z(i)'  Lelwe  des  Infractionen  und  Ftexionen  der  GehiirmuUer,  8vo.,  Giessen,  1850. 


OF    FLEXIONS    OF    THE    WOMB.  169 

Any  positive  obliteration  of  tlie  internal  os,  however,  which  Vir- 
chow  has  sometimes  met  with  in  aged  persons,  is  not  merely  a 
very  rai-e  occurrence,  but  is  probably  due  in  large  measure  to  the 
natural  tendency  to  closure  of  the  internal  os  in  old  age,  and  which 
the  flexion  of  the  uterus,  though  it  may  have  increased,  has  not 
originated. 

One  or  two  other  consequences  of  flexion  of  the  w^omb  deserve 
mention,  though  I  believe  that  the  degree  to  which  they  exist  ad- 
mits of  very  wide  variation.  The  body  and  fundus  of  the  w^omb 
are  very  apt,  as  the  result  of  their  altered  position,  to  become  the 
seat  of  congestion  ;  a  congestion  that  may  be  very  intense,'  and 
with  the  existence  of  which  it  is  reasonable  to  associate  the  dis- 
position to  menorrhagia  that  is  so  prominent  a  feature  in  many 
cases  of  this  kind.  Moreover,  a  part  that  is  the  frequent  seat  of 
congestion  tends  to  enlarge,  and  hence  the  misplaced  body  and 
fundus  of  the  womb  often  become  hypertrophied,  wdiile  the  difii- 
culty  of  escape  of  the  secretions,  when  the  angle  of  flexion  is  very 
acute,  helps  to  increase  the  dimensions  of  the  uterine  cavity,  a  re- 
sult of  the  occurrence  of  which  the  uterine  sound  informs  us  in  a 
very  large  number  of  instances. 

The  condition  of  the  cervix  uteri  is  seldom  natural,  but  there  is 
generall}'  a  profuse  secretion  from  its  glandular  apparatus,  while 
the  edges  of  the  os  uteri  are  usually  red,  and  their  epithelium  is 
often  al)raded,  a  condition  dependent  doubtless  on  the  state  of 
general  irritation  of  the  cervix.  To  the  touch  the  margins  of  the 
OS  rarely  present  any  marked  deviation  from  a  healthy  condition, 
while  the  os  itself  (at  least  in  retroflexion,  concerning  which  my 
observations  are  more  numerous  than  concerning  anteflexion),  is 
often  open  so  as  to  admit  the  tip  of  the  finger.  The  anterior  lip, 
too,  in  cases  of  retroflexion,  is  usually  shorter  than  the  posterior — 
an  alteration  of  the  natural  relations  probably  due,  as  Sommer 
suggests,  to  merely  mechanical  causes,  and  to  the  dragging  out  of 
its  ]>lace  of  the  lip  on  that  side  which  corresponds  to  the  convexity 
of  the  flexed  womb. 

In  tlie  cases  to  which  reference  has  hitherto  been  made,  the 
uterine  misplacement  would  seem  to  be  an  acquired  condition, 
though  one  coming  on  at  different  periods  of  life,  and  under  the 
influence  of  causes  which,  sometimes  at  least,  are  obscure.  There 
are  other  instances,  however,  in  which  obliquity  of  the  uterus  for- 
wards, backwards,  or  to  eitlier  side,  is  the  result  of  conqenital  mal- 
formation, associated  with  marked  difl'erence  in  the  length  of  the 
womb  and  broad  ligaments  on  the  two  sides,  or  dependent  on  un- 
equal development  of  the  two  halves  of  the  womb  itself.  In  one 
instance  in  which  I  found  the  womb,  in  an  unmarried  girl,  aged 
eigliteen,  oblique  in  form,  and  inclined  towards  the  right  side,  the 
left  ligamentum  ovarii  was  1.2  inch  fin  length,  while  that  of  the 
right  side  measured  only  .6  of  an  inch  ;  and  in  the  body  of  another 

1  As  in  tlio  drawing  of  the  antefloxed  uterus  at  figs.  5  and  G  of  plate  ix  of  Boivin 
and  Diiir^'s  Atlas. 


170  MISPLACEMENTS    OP    THE    UTERUS. 

unmarried  girl,  aged  nineteen,  likewise  free  from  all  trace  of 
uterine  disease,  the  womb  was  unequal  in  size,  its  right  corner 
being  .3  of  an  inch  higher  than  the  left.  Professor  Tiedemann,^ 
who  was  the  first  to  call  special  attention  to  this  condition,  has 
published  in  his  treatise  on  the  subject  several  drawings,  which 
represent  very  extreme  degrees  of  uterine  obliquity  and  malfor- 
mation. There  is  nothing  to  surprise  us  in  the  occasional  want 
of  symmetry  of  an  organ  formed  as  the  uterus  is,  in  great  measure, 
by  the  coalescence  of  two  lateral  halves  or  cornua.  At  the  same 
time  it  seems  very  doubtful  whether  such  inequality  of  the  womb 
gives  rise  to  any  symptom,  or  whether  in  the  event  of  pregnancy 
and  labor  occurring,  it  produces  any  of  those  formidable  results 
whicli  Deventer  and  other  practitioners  of  midwifery  a  hundred 
and  fifty  years  ago  referred  to  obliquity  of  the  uterus  ;  opinions 
which  even  at  the  present  day  are  not  altogether  exploded.  I  refer 
to  these  conditions  now  chiefly  for  the  purpose  of  impressing  on 
you  the  by  no  means  needless  caution,  that  since  uterine  obliquity 
may  depend  on  causes  wholly  beyond  remedy,  so  prudence  dic- 
tates that  when  it  gives  rise  to  no  symptoms  we  should  abstain 
from  all  endeavors  at  cure,  which,  to  say  the  least,  are  needless, 
which  very  likely  may  be  fruitless,  which  possibly  may  prove  very 
mischievous. 


LECTURE    XII. 

MISPLACEMENTS  OF  THE  UTERUS. 

Versions  and  Flexions  of  the  Uterus. 

Symptoms.     Conflicting  opinions  concerning  them ;  how  they  may  to  a  certain 

extent  be  reconciled.     Alleged  symptoms  not  always  due  to  misplacements. 

Evidence  of  statistics;    production  of  symptoms  connected  with  other  causes 

acting  on  the  womb.    Enumeration  of  symptoms,  and  separate  examination  of 

each. 
Diagnosis.     Use  of  the  sound. 
Treatment.    Historical  sketch  of  opinion  and  practice  on  the  subject.    The  uterine 

supporter;  reasons  for  rejecting  mechanical  contrivances,  and  for  preferring 

palliative  treatment.     Plan  of  treatment  described. 

"We  have  hitherto  been  occupied  with  the  examination  of  the 
nature  of  the  various  versions  and  flexions  of  the  uterus,  and  have 
had  occasion,  in  the  course  of  this  inquiry,  to  notice  conflicting 
opinions  and  opposing  statements  which  it  was  very  difficult,  wliich 
it  was  sometimes  indeed  quite  impossible,  to  reconcile.  Such  dis- 
crepancies become  more  numerous  and  more  frequently  irrecon- 
cilable as  we  pass  to  the  study  of  the  symptoms  which  these  mis- 
placements produce,  and  to  the  consideration  of  the  treatment 
that  they  require.    The  symptoms  are  by  some  described  as  being 

1  Von  den  Duverneyschen  Drilsen  des  Weibes,  und  der  schiefen  Gestaltunr/  iind  Layc 
der  Gebdrmutter ,  4to.,  Heidelberg,  1840. 


SYMPTOMS     OF    FLEXIONS    OF    THE    WOMB.  171 

both  numerous  and  characteristic,  and  the  appropriate  treatment' 
is  by  them  alleged  to  be  both  simple,  safe,  and  successful;  while 
others  deny  that  the  malpositions  taken  by  themselves  produce  any 
symptoms,  and  assert  that  tlie  proposed  treatment,  while  attended 
by  very  considerable  risk,  is  wholly  inadequate  to  the  removal  of 
the  evil  which  it  is  intended  to  cure.  Each  of  these  opinions,  too, 
is  maintained  by  men  equal  in  the  eminence  of  their  position,  in 
their  practical  experience,  and  their  good  faith.^ 

The  alleged  results  of  these  uterine  misplacements  maybe  briefly 
stated  to  consist  in  disor(|er  of  menstruation,  wdiich  is  usually  both 
excessive  and  painful,  in  leucorrhocal  discharge,  in  pain  and  diffi- 
culty both  in  defcci\tion  and  micturition,  and  in  pain  in  the  pelvis 
generally,  though  usually  most  severe  in  that  part  of  the  pelvis 
towards  which  the  fundus  uteri  is  turned  or  flexed,  while  sterility 
is  a  farther  consequence  stated  to  be  produced  by  flexions  of  the 
womb  in  a  very  large  number  of  instances.  In  these  symptoms 
it  is  obvious  that  there  is  much  that  of  itself  cannot  be  regarded 
as  pathognomonic  of  one  uterine  aflection  rather  than  of  another, 
since  they  constitute  just  that  train  of  ailments  which,  in  varying 
combinations  and  with  varying  intensity,  we  meet  with  in  almost 
every  disorder  of  the  womb.  To  this,  however,  it  would  not  be 
right  to  attach  much  importance,  since  the  uterine  ailments  that 
manifest  themselves  by  some  one  characteristic  symptom,  or  by 
characteristic  combinations  of  symptoms,  are  very  few  indeed. 
Just  as  sickness  may  depend  on  sympathetic  disturbance  of  the 
stomach  during  pregnancy,  or  on  irritability  of  the  organ  conse- 
quent on  some  exhausting  disease,  or  on  the  presence  of  sarcinpe 
in  its  cavity,  or  on  the  development  of  cancer  in  its  walls,  so  may 
the  same  symptoms  depend  in  one  case  on  trivial  disorder  of  the 
womb,  in  another  on  its  incurable  disease.  The  symptoms  are  like 
the  alarm-bell,  which  gives  notice  of  a  something  wrong,  and  serves 
to  awaken  attention  ;  it  is  not  fair  to  expect  that  they  should  at 
once  inform  us  not  merely  what  part  sufters,  but  what  the  exact 
cause  is  on  which  those  sulFerings  depend. 

Another  circumstance,  however,  has  been  much  insisted  on  as 
proof  of  the  unreality  of  the  alleged  symptoms  of  tliese  misplace- 
ments— namely,  that  in  many  instances  where  accident  has  re- 
vealed the  existence  of  uterine  misplacement,  the  functions  of  the 
womb  were  ])erformed  in  all  respects  naturally  and  painlessly. 
But  from  this  fact  we  must  be  careful  not  to  draw  too  wide  an 
inference,  for  even  the  early  stages  of  uterine  cancer  ]^ass  not  in- 
fre((uently  unrevealed  by  any  symptoms  of  disorder  of  the  womb; 
and  fibrous  tumors  often  attain  a  great  development  before  their 
existence  is  suspected,  or  a  lull  of  their  symptoms  takes  place  so 
complete  and  of  such  long  continuance  that  careful  examination 
alone  convinces  us  of  the  persistence  of  the  evil  which  had  pro- 

1  Tlio  pnljlisliod  report  (if  tlie  discussion  at  Paris  on  tiiis  subji'ot,  coiitaiMcd  in 
the  liiillrtin  Or  I'AcadSinie  de  Meile.cine  for  18r)3-r)4,  vol.  xix,  pp.  778-97(j,  is  a  most 
reniarlcahle  illustration  of  the  extent  to  which,  in  an  uncertain  science,  ditJerenco 
is  possible. 


172  IMPORTANCE    OF    FLEXIONS 

duced  them.  There  is  a  French  phrase  which  expresses  excellently 
well  the  character  of  those  in  whom  both  these  misplacements  and 
other  uterine  ailments  are  generally  attended  by  the  most  urgent 
symptoms:  they  are  persons  quis'ecoutent  vivre, — who  watch  them- 
selves live ;  and  the  ailments  of  which  another  would  be  barely 
conscious,  are  to  them  sources  of  exquisite  torture.  The  ailment 
may  be  a  real  one,  and  yet  it  may  be  the  wiser  and  more  hopeful 
course  to  try  to  remedy  the  state  of  constitution  which  exaggerates 
the  patient's  suft'e rings,  rather  than  to  meddle  with  the  local  affec- 
tion that  excites  their  present  manifestations. 

But  there  are  facts  of  a  different  kind  which  show  that  the  im- 
portance of  these  ailments  has  probably  been  overrated;  and  they 
are  furnished  by  cases  where  the  removal  of  the  misplacement, 
though  no  other  uterine  ailment  was  discoverable,  has  not  been 
followed  by  any  mitigation  of  the  patient's  sufferings;  as  well  as 
by  others  in  which  the  symptoms  once  present  have  ceased,  in  spite 
of  the  persistence  of  the  misplacement.  A  woman,  aged  twenty- 
two,  had  been  married  four  years,  during  which  period  she  mis- 
carried four  times;  on  the  last  occasion,  at  the  sixth  month,  seven 
months  before  coming  under  my  care.  She  suffered  from  the  date 
of  her  last  miscarriage  from  pain,  leucorrhcea,  and  profuse  men- 
struation, accompanied  by  discharge  of  coagula;  and  on  examina- 
tion her  uterus  was  found  retrofiected,  the  fundus  being  directed 
not  only  backwards,  but  also  to  the  left  side.  Twenty-seven  months 
after  her  last  abortion  she  became  pregnant,  but  the  misplacement 
continued  during  the  early  months  of  pregnancy,  as  was  ascertained 
by  examination.  She  gave  birth  to  a  live  child  at  the  full  period 
of  utero-gestation,  and  expressed  herself  as  feeling  afterwards  per- 
fectly well ;  but  her  womb  was  still  retrofiected,  and  I  found  it 
occupying  its  old  position  fifteen  months  after  her  delivery,  or  four 
years  and  a  quarter  after  the  miscarriage  to  which  she  originally 
referred  all  her  sufferings. 

A  woman,  twenty-eight  years  old,  had  been  married  nine  years, 
had  given  birth  to  one  child  in  the  second  year  of  her  marriage, 
and  five  years  before  I  saw  her  had  undergone  some  operation  for 
the  removal,  as  she  said,  of  a  uterine  tumor.  Ever  since  this 
operation  she  stated  herself  to  have  suffered  from  leucorrhoeal  dis- 
charge, with  pain  of  a  burning  character  in  the  neighborhood  of 
the  uterus,  much  aggravated  by  defecation  or  by  sexual  intercourse, 
and  being  especially  severe  at  the  menstrual  periods.  The  peri- 
neum was  somewhat  torn,  the  uterus  low  down,  its  orifice  circular, 
with  perfectly  smooth  edges,  and  its  posterior  lip  was  connected 
firmly  to  the  posterior  vaginal  wall,  and  cicatrices  ran  from  it  for 
some  distance  to  the  left  side  of  the  vagina.^  The  uterine  sound 
entered  easily  with  its  concavity  directed  backwards  for  two  inches 

1  It  is  not  without  interest,  as  illustrative  of  the  futility  of  many  of  the  sugcces- 
tions  made  for  the  cure  of  these  ailments,  to  notice  the  existence  in  this  case  of  that 
very  condition  of  adhesion  between  the  cervix  uteri  and  the  vaginal  wall,  on  tlie 
production  of  which  by  surgical  interference  M.  Amussat  has  insisted  as  so  im- 
portant a  means  of  cure. 


OF    UTERUS    OVERRATED.  173 

and  a  half;  on  turning  it  round  the  tumor  completely  disappeared. 
For  the  first  four  or  five' days  after  the  replacement  of  the  uterus 
the  patient  expressed  herself  as  feeling  much  relieved;  but  her 
symptoms  then  returned,  and  have  continued  just  the  same  as 
before  for  four  years  and  a  half,  during  which  time  I  have  had  the 
opportunity  of  frequently  examining  the  condition  of  tlie  uterus, 
and  have  always  found  it  occupying  its  natural  position. 

But  be  the  value  of  cases  such  as  these  what  it  may,  as  proving 
on  the  one  hand  that  flexions  of  the  womb  do  not  of  necessity  give 
rise  to  any  suffering,  and  on  the  other,  that  the  removal  of  a  flex- 
ion of  the  organ  may  not  be  followed  by  the  least  relief  to  a  pa- 
tient's distress,  the  fact  still  remains,  that  misplacement  of  the 
womb  is  in  very  many  instances  accompanied  by  various  uterine 
ailments,  such  as  were  not  experienced  before  its  occurrence.  The 
question,  however,  suggests  itself  with  reference  to  these  cases,  as 
to  whether  their  history  presents  any  peculiarity  which  would  war- 
rant our  believing.that  the  symptoms  are  due  not  simply  to  the 
mis[)lacement,  but  to  some  other  morbid  condition  witli  which  the 
misplacement  is  associated,  or  to  the  two  causes  together  ?  Xow, 
there  are  circumstances  which  appear  to  favor  the  opinion,  that 
in  the  majority  of  instances  the  symptoms  are  due  not  to  misplace- 
ment alone,  but  to  misplacement  accompanied  by  some  other  mor- 
bid state  of  tlie  womb. 

The  fact,  that  of  131  instances  of  version  or  flexion  of  the  womb,* 
115  .occurred  among  married  women,  16  only  among  those  who 
were  single,  tends  to  connect  it  with  the  performance  of  the  liigh- 
est  functions  of  the  sexual  system — with  pregnancy,  delivery,  and 
their  consequeuces.  This  view  is  further  confirmed  by  the  cir- 
cumstance that  the  age  at  which  the  majority  of  women  sufter 
from  its  symptoms  coincides  with  that  period  of  life  at  which  those 
functions  are  in  most  active  exercise.  Valleix  states  that  the 
majority  of  his  patients  referred  the  commencement  of  their  ail- 
ments to  between  the  ages  of  twentj^  and  thirty  years  ;  while  the 
fact  that  forty-nine  out  of  the  sixty-three  patients  of  whose  cases 
I  have  preserved  a  record  were  under  forty  years  old  at  the  time 
of  their  coming  under  my  cai'c,  points  in  the  same  direction. 
Moreover,  in  thirty-four  out  of  fifty-seven  cases  of  married  women 
referred  to  by  M.  Valleix,  and  in  twenty-one  of  my  fitty-eight  (or 
twenty-one  of  forty-six,  if  for  the  moment  twelve  cases  where 
marriage  liad  proved  sterile  are  omitted),  the  patients  referred  the 
commencement  of  their  ailments  to  delivery  or  miscarriage  ;  to  a 
time,  in  short,  when  the  womb  was  larger,  heavier,  and  more 
alnindantly  supplied  with  blood  than  at  other  seasons,  when  its 
recently  stretclied  supports  were  less  able  than  at  other  times  to 
keep  it  in  its  proper  position,  and  when  those  attacks  of  circum- 
scribed peritonitis,  by  which  adhesions  are  ])roducod  between  it 
and  the  adjacent  parts,  are  specially  likely  to  occur.     The  case 

'  The  above  numbers  are  derived  from  the  sixty-eight  cases  of  Valleix,  with 
sixty-three  of  my  own. 


174  /  SYMPTOMS    OF    UTERINE 

related  in  the  last  Lecture  (p.  162)  shows  how  in  these  conditions 
the  enlarged  uterus  may  be  retroverted,  and  shows  further  how, 
in  spite  of  its  gradual  reduction  in  size,  the  misplaceuient  may 
still  continue  ;  its  symptoms /.aggravated  after  each  fresh  miscar- 
riage, which  reproduced,  though  in  a  slighter  degree,  the  same 
train  of  evils  as  attended  the  first  occurrence  of  the  accident.  Ot 
the  remaining  thirty  seven' patients,  three  had  fibrous  tumors  in 
the  uterine  walls,  so  that  the  misplacement  of  the  womb  might  be 
regarded  as  in  part  due  to  their  presence,  while  in  a  fourth  there 
was  a  small  tumor,  probably  ovarian,  behind  the  uterus,  which 
not  merely  retroflected  it,  but  having  become  adherent  both  to  the 
womb  and  to  the  rectum,  prevented  the  uterus  from  resuming  its 
proper  position  even  after  the  tumor,  in  which  suppuration  took 
place,  had  discharged  its  contents  by  the  bowels ;  and  in  a  fifth 
the  misplacement  was  apparently  consequent  on  the  formation  ot 
an  abscess  between  the  uterus  and  rectum,  by  which  the  organ 
had  been  retroverted  and  finally  bound  down  by  adhesions  in  its 
unnatural  position.  Four  patients,  one  of  whom  was  unmarried, 
referred  their  symptoms  to  a  menstrual  period,  which  had  been 
attended  by  an  unusual  amount  ot  suflering,  and  one  dated  them 
from  intemperate  sexual  intercourse.  Once  the  symptoms  suc- 
ceeded to  an  attack  of  vaginitis,  which  was  most  likcl}-  accom- 
panied by  peritoneal  inflammation,  since  the  anteflected  womb 
was  bound  down  in  its  unnatural  position  ;  and  in  one  more,  in 
whom  the  enlarged  and  anteverted  womb  was  similarly  fixe.d  in 
the  pelvis,  there  was  a  history  of  abdominal  pain  and  tenderness 
occurring  causelessly  five  years  before.  Six  times  the  accident 
seemed  to  have  succeeded  to  some  sudden  violent  exertion,  and 
in  one  instance  (that  in  which  the  symptoms  persisted  after  the 
removal  of  the  misplacement),  the  patient  dated  her  suftering  from 
some  operation  performed  five  years  previously,  apparently  for  the 
removal  of  a  polypus.  There  still  remain  twenty  patients,  con- 
cerning the  cause  of  w'hose  ailments  no  adequate  explanation  is 
given.  It  is  not  without  interest,  however  to  observe  that  in  al- 
most all  of  these  cases,  the  symptoms  had  come  on  very  gradually, 
and  the  misplaced  uterus  was  in  the  great  majority  of  instances 
much  enlarged.  The  subsidence  of  the  symptoms  and  the  diminu- 
tion in  size  of  the  womb  took  place  simultaneously.  Sometimes 
as  the  organ  grew  smaller,  it  resumed  its  natural  position  of  its 
own  accord,  while  in  other  cases  it  remained  misplaced,  but  there 
did  not  seem  to  be  any  invariable  connection  between  the  com- 
pleteness of  the  patient's  recovery  and  the  return  of  the  womb  to 
its  proper  situation. 

It  seems,  then,  that  in  by  far  the  greater  number  of  instances, 
the  development  of  all  the  symptoms  of  flexion  or  version  of  the 
uterus  coincided  with  the  operation  of  some  cause  that  increased 
the  size  of  the  w^omb,  or  produced  congestion  of  the  pelvic  viscera; 
and  further,  it  may  be  added,  that  the  almost  immediate  relief 
which  followed  rest,  local  depletion,  and  the  due  regulation  of  the 
bowels,  seems  to  show  that  to  these  associated  ailments,  rather 


FLEXIONS    ACCOUNTED    FOR.  175 

than  to  the  mere  misplacement  of  tlie  womb,  the  patient's  siifierings 
were  to  be  attributed.  IN'ot  infrequently,  however,  the  relief, 
though  striking,  was  of  short  duration ;  and  the  patient  had  not 
long  followed  hpr  usual  avocations,,or  not  long  returned  to  her 
husband's  bed,  before  many  of  her  former  symptoms  returned. 
But  tliis  is  by  no  means  peculiar  to  misplacement  of  the  womb  ;  for 
we  SCO  illustrations  of  it  in  the  increased  suffering  which,  in  almost 
every  uterine  ailment,  attends  upon  the  menstrual  period,  and  iu 
the  aggravation  of  all  previous  uterine  discomfort,  which  in  many 
women  succeeds  to  marriage,  and  which  is  sometimes  the  occasion 
of  ailments  being  brought  to  light  whose  very  existence  was  pre- 
viously unsuspected.^ 

A  woman,  aged  thirty-five,  was  admitted  into  St.  Bartholomew's 
Hospital,  and  gave  the  following  history  of  herself:  She  had  been 
married  eleven  months,  but  had  never  been  pregnant.  Previous 
to  her  marriage  her  health  had  been  good,  with  the  exception  that 
menstruation,  though  regular,  was  always  very  painful.  Since  her 
marriage,  however,  she  had  suffered  much  from  constant  aching 
pain  round  the  loins,  felt  most  in  walking,  and  constant  desire  to 
pass  water,  while  her  menstruation  had  become  very  frequent  in 
its  return.  On  making  an  examination,  the  os  uteri,  which  was 
small  and  circular,  was  found  directed  backwards ;  while  above 
the  anterior  wall  of  the  vagina  a  tumor  of  a  rounded  form  was 
felt  pressing  forward  against  the  bladder,  and  could  also  be  dis- 
tinguished by  means  of  a  sound  introduced  into  that  organ.  I 
imagined  the  body  to  be  formed  by  the  anteflected  uterus;  though, 
after  careful  and  repeated  examinations,  in  the  course  of  which  I 
endeavored  successfully  to  introduce  the  uterine  sound,  I  changed 
this  opinion,  and  came  to  the  conclusion  that  it  was  a  fibrous  tumor 
growing  from  the  anterior  uterine  wall.  Whichever  view  be  cor- 
rect, the  case  equally  well  illustrates  the  fact  that  a  uterine  ailment 
may  remain  quiescent,  as  far  as  the  production  of  symptoms  is 
concerned,  for  an  indefinite  period,  while  yet  it  may  be  the  cause 
of  much  suffering,  if  any  accident  gives  rise  to  an  increased  afflux 
of  blood  towards  the  womb. 

Bearing  in  mind,  then,  their  compound  origin,  we  may  next 
inquire  into  the  nature  of  the  symptoms  that  usually  accompany 
veik^ions  or  flexions  of  the  womb.  In  the  two  instances  where 
the  misplacement  occurred  suddenly  as  the  result  of  over-exertion 
or  straining,  much  pain  was  at  once  experienced,  and  was  referred 
to  the  neighborhood  of  the  uterus;  while  in  the  case  of  retrover- 
sion there  were  considerable  difficulty  in  micturition  and  frequent 

1  This  estimate  of  the  ordinarily  small  importance  of  simple  uterine  flexions 
coincides  very  closely  with  the  conclusions  at  which  Scanzoni  ha.s  arrived,  and 
wiiich  he  holds  so  decidedly  that  he  jirints  in  large  type  in  the  third  edition  ol"  his 
boOk.  ''  P'lexions  of  the  uterus  are  never  of  much  imjHirtance,  nrvcr  give  rise  to 
serious  evils,  except  when  some  other  atfection  of  the  uterine  suhstance  is  associated 
with  them."— 0/>.  cit.,  p.  90.  The  conclusion,  too,  to  which  ^V.  Hernutz  is  con- 
ducted by  his  and  M.  Goupil's  elaborate  investigation  is,  that  "uterine  deviations, 
with  till.'  exception  of  descent  and  prolapsus  of  the  organ,  giv(>  rise,  when  uncom- 
plicated, to  no  kind  of  functional  disorder." — Op.  cit.,  vol.  ii,  p.  717. 


176  SYMPTOMS    OF     UTERINE 

desire  to  pass  water.  In  other  cases,  however,  the  supervention 
of  the  symptoms  was  gradual ;  discomfort  ahout  the  pelvis  accom- 
panied by  unusually  profuse,  and  often  unusually  painful  men- 
struation, being  the  symptoms  which  first  excited  the  patient's 
notice,  and  by  their  persistence  and  their  increase,  compelled  her 
to  seek  for  relief. 

The  following  were  the  more  prominent  symptoms  in  the  sixty- 
three  cases  of  version  or  flexion  of  the  uterus  of  which,  down  to 
the  present  time,  I  have  preserved  a  record  : 

In  the  total  In  twenty  of  them  the  uterus  was 

sixty  three  cases.  auteverteii  or  anteflexed. 

Menorrhagia,      ....     20        3 

Dj-smenorrhoea, ....     20         8 

Leucorrhoea,        ....     25        8 

Pain,  or  other  discomfort  1    ni  7 

in  micturition,      .     .      / 

Pain, 51         17 

Difficult  or  painful  defe-  }    24  3 

cation / 

Of  the  above  sixty-three  patients,  fifty-eight  were  married,  of 
whom  twelve  were  sterile.  The  remaining  forty-six,  of  whom  all 
but  one  were  under  forty  years  of  age,  had  given  birth  to  one 
hundred  and  twenty-four  children,  and  had  had  forty  miscarriages; 
numbers  which  yield  results  ditt'erent  but  little  from  those  which 
we  meet  with  among  persons  afllicted  with  uterine  disease  in 
general ;  and  whose  labors  amount  to  2.7,  their  miscarriages  to 
0.47  to  a  marriage,  while  one  in  8.5  of  the  total  number  proves 
sterile. 

The  above  enumeration  of  symptoms,  and  of  their  comparative 
frequency,  which  tallies  in  the  main  remarkably  with  the  state- 
ments of  M.  Valleix  on  the  subject,  must  be  sufiicient  to  show  that 
either  the  misplacement  itself,  or  the  state  of  the  uterus  associated 
with  it,  is  adequate  to  produce  much  positive  sufiering  and  much 
functional  disorder.  The  pain  which  was  experienced  in  all  but 
twelve  of  my  cases,  and  in  sixty-four  out  of  sixty-five  of  those  of 
M.  Valleix,  varied  much  in  its  intensity.  It  was  a  constant  sense 
of  pain  and  aching  in  the  back  and  loins,  and  of  pain  shooting 
down  the  thighs  ;  often,  though  not  always,  accompanied  by  a 
sense  of  bearing  down,  and  by  sensations  of  the  same  kind  a^  in 
general  attend  ordinary  descent  of  the  womb,  though  more  dis- 
tressing in  their  character.  In  very  many  sexual  intercourse  was 
attended  by  great  pain,  while  the  sufiering  it  produced  had  led  in 
some  instances  to  its  complete  discontinuance.  Those  patients  in 
whom  the  abiding  pain  was  the  most  considerable  sufiered  also 
from  occasional  attacks  of  paroxysmal  pain,  which  was  sometimes 
of  extreme  intensity,  and  had  the  character  of  hysterical  colic  such 
as  one  meets  with  occasionally  in  various  uterine  ailments,  and 
such  as  is  especially  associated  with  dysmenorrhoea.  I  have  not 
been  able  to  ascertain  that  there  is  any  constant  relation  between 
the  direction  in  which  the  womb  isfiexed  and  the  seat  of  the  pain 
in  the  anterior  or  posterior  part  of  the  pelvis,  though  difficult  and 


FLEXIONS     ACCOUNTED     FOR.  177 

• 

painful  defecation  appears  to  be  much  more  frequent  in  cases 
where  the  womb  is  retroflexed  or  retroverted  than  in  those  where 
it  is  turned  or  bent  forwards.  I  doubt,  however,  very  mucli  the 
extent  to  which  any  of  these  symptoms  can  be  referred  to  the  mere 
mechanical  effects  of  the  clisphacement  of  the  womb,  for  in  five 
out  of  the  fourteen  cases  in  which  difficult  micturition  attended 
misplacement  of  the  womb  backwards,  the  organ  was  retroflexed 
and  not  retroverted,  and  consequently  the  bladder  was  subjected 
to  no  kind  of  pressure  ;  while,  moreover,  in  thirteen  cases  of  ver- 
sion or  flexion  of  the  womb  forwards,  the  bladder  was  relieved 
without  cither  pain  or  difficulty.  Pain  and  difficulty  in  defecation, 
too,  are  by  no  means  such  constant  attendants  upon  retroflexion 
as  might  be  reasonably  expected  if  they  depended  upon  a  simply 
mechanical  cause.  The  symptom  was,  indeed,  for  a  long  time 
regarded  as  of  purely  mechanical  origin,  and  the  presence  of  mucus 
in  the  evacuations  was  looked  upon  as  conclusive  evidence  of  the 
irritation  of  the  bowel  by  the  misplaced  womb.  Further  observa- 
tion has  shown,  however,  that  this  symptom  is  by  no  means  con- 
stant in  cases  even  of  very  marked  retroflexion  ;  that  further,  it  is 
often  absent  in  cases  where  the  growth  of  fibrous  tumors  from  the 
posterior  wall  of  the  uterus  exerts  very  considerable  pressure  on 
the  bowel,  while  it  is  far  from  uncommon  in  various  uterine  ail- 
ments attended  with  much  irritation  of  the  neighboring  viscera, 
even  though  unaccompanied  by  any  enlargement  or  misplacement 
of  the  womb.  The  same  fact  holds  good  still  more  absolutely  with 
reference  to  constipation,  for  the  retroflected  fundus  is  never  found 
so  to  compress  the  rectum  as  to  interfere  with  the  easy  intro- 
duction of  the  finger  into  the  bowel,  and  consequently  cannot 
mechanically  prevent  the  escape  of  its  contents;  while  further,  no 
accumulation  of  ffeces  is  found  to  take  place  above  the  fundus  of 
the  womb  ;  and  lastly,  constipation,  even  more  obstinate  than  that 
observed  in  these  cases,  attends  upon  a  large  number  of  ailments, 
especially  of  an  aneemic  or  hysterical  kind,  in  which  there  is  no 
local  affection  of  the  uterus.  The  leucorrhoea,  the  dysmenorrhoea, 
and  the  menorrhagia,  though  of  very  frequent  occurrence,  are 
perhaps  less  characteristic  than  the  symptoms  already  enumerated, 
inasmuch  as  they  are  frequent  attendants  upon  so  many  uterine 
disorders.  It  is,  however,  worth  notice  that  the  forty  instances  of 
disturbance  of  the  menstrual  function  occurred  in  thirty-nine 
different  persons  ;  but  I  am  not  prepared  to  state  that  there  was 
greater  flexion  of  the  womb  where  the  menstruation  was  most 
painful  than  in  other  cases,  or  more  marked  enlargement  or  ap- 
parent congestion  of  the  organ  where  the  menstruation  was  most 
profuse. 

Lastly,  with  reference  to  the  influence  of  these  conditions  on 
fecundity.  Of  the  fifty-eight  married  women  one  had  become  a 
widow,  and  one  had  passed  the  childbearing  age,  before  any 
symptoms  of  uterine  ailment  appeared,  while  in  seven  the  symp- 
toms were  of  less  tlian  a  year's  duration,  and  consequently  there 

12 


178  UTERINE    FLEXIONS: 

had  not  been  time  for  the  influence  of  the  ailment  in  this  respect 
to  become  evident. 

Of  the  remaining  forty-nine,  six  gave  birth  to  live  children  at 
the  full  period,  after  the  womb  had  been  misplaced;  and  one  of 
this  number  had  five  live  children  at  the  full  term  of  utero-gesta- 
tion,  in  spite  of  the  existence  for  fifteen  years  of  all  the  signs  of 
retroflexion  of  the  uterus. 

In  one  of  the  above  six,  pregnancy  was  preceded  by  the  replace- 
ment of  the  organ  ;  but  in  the  other  five,  not  only  was  the  womb 
misplaced  at  the  time  of  conception,  but  was  ascertained  to  con- 
tinue so  after  delivery. 

Five  having  previously  given  birth  to  living  children,  miscarried 
after  the  development  of  symptoms  of  uterine  misplacement;  and 
in  one  of  the  number  miscarriage  had  twice  occurred,  and  in  an- 
other eleven  times,  while  twenty-one,  having  previously  given 
birth  to  one  or  more  living  children,  had  passed  more  than  a  year 
since  the  commencement  of  the  symptoms  without  conceiving.  In 
six  of  this  number,  however,  though  still  within  the  childbearing 
age,  conception  had  not  taken  place  for  from  two  to  five  years 
previous  to  the  commencement  of  tiie  symptoms  of  misplacement 
of  the  womb. 

The  above  detail  of  symptoms  shows,  I  think,  that  while  versions 
and  flexions  of  the  womb  by  no  means  invariably  produce  either 
local  suftering  or  functional  disturbance,  their  presence  or  absence 
is  yet  far  fron)  being  a  matter  of  indiftcrence,  and  we  must  admit 
them  as  constituting  a  distinct  class  of  by  no  means  unimportant 
ailments  of  the  womb.  But  even  though  they  were  themselves 
of  but  little  moment,  it  would  nevertheless  be  very  necessary  that 
we  shouhl  learn  to  dutinguhh  them  from  other  and  more  serious 
uterine  ailments,  with  which  some  of  thcin  are,  on  a  superficial 
examination,  very  likely  to  be  confounded. 

With  ordinary  care,  indeed,  any  misplacement  of  the  whole 
uterus,  assuming,  as  it  usually  does,  the  form  of  retroversion,  can 
scarcely  be  overlooked  or  mistaken,  for  the  fundus  uteri  thrown 
backwards,  and  often  downwards,  into  the  hollow  of  the  sacrum, 
and  the  mouth  of  the  womb  directed  forwards,  and  tilted  upwards 
against  the  symphysis  of  the  pubes,  are  characteristic  indications 
of  the  change  in  its  position.  The  sources  of  fallacy  are,  however, 
far  more  numerous  in  those  cases  in  which  the  organ  is  flexed  and 
its  body  is  bent  upon  the  cervix,  producing  a  tumor  which  may  be 
mistaken  for  ovarian  disease,  or  for  a  fibrous  tumor  of  the  uterus, 
or  for  one  of  those  extravasations  of  blood  around  the  substance  of 
the  womb,  to  which,  under  the  name  of  uterine  h?ematocele,  atten- 
tion has  of  late  years  been  especially  directed.  In  cases  where  the 
uterus  is  bent  forwards,  the  sources  of  error  are  less  numerous  than 
in  cases  of  its  retroflexion,  and  I  am  not  aware  of  anything  except 
a  fibrous  tumor  of  the  anterior  uterine  wall  which  is  likely  to 
throw  uncertainty  upon  our  diagnosis,  though  I  have  found  the 
discrimination  between  flexion  of  the  womb  and  the  presence  of  a 
fibrous  tumor  in  its  wall  to  be  sometimes  so  difficult  as  to  be 


THEIR    DIAGNOSIS.  179 

almost  impossible.  The  tumor  formed  by  a  flexion  of  the  womb 
usually  begins  immediately  above  its  cervix,  and  the  substance  of 
the  organ  may  be  traced  passing  over  into  it.  At  the  same  time 
no  enlargement  of  the  uterus  can  be  felt  by  the  finger  carried  in 
front  of  the  cervix  in  cases  of  retroflexion,  or  behind  it  in  cases  of 
anteflexion,  while  if  the  patient  lie  upon  her  back,  and  pressure  is 
made  with  one  hand  over  the  pubes  and  the  other  in  the  vagina, 
the  absence  of  any  pelvic  tumor  may  in  general  be  readily  ascer- 
tained. Moreover,  in  many  instances,  pressure  with  the  finger  in 
the  vagina  upon  the  uterine  tumor  imparts  to  it  a  degree  of 
mobility  without  at  all  altering  the  position  of  the  cervix,  such  as 
would  not  be  possible  in  the  case  of  a  fibrous  outgrowth  from  the 
organ.  This,  however,  is  not  always  practicable ;  for  on  the  one 
hand,  the  tenderness  of  the  flexed  womb  not  infrequently  prevents 
any  steady  pressure  upon  it  being  borne  by  the  patient ;  and  on 
the  other,  steady  and  long-continued  pressure  does  not  always 
modify  the  position  of  the  organ, — and  this  even  though  no  morbid 
adhesion  connect  its  fundus  with  adjacent  parts.  In  a  very  large 
number  of  the  doubtful  cases  we  should  remain  in  uncertainty  for 
a  very  long  time,  and  come  at  length  to  a  hesitating  decision,  if  it 
w^ere  not  for  the  help  afforded  us  by  the  uterine  sound.  If  this 
instrument  is  introduced  with  its  concavity  directed  either  back- 
wards or'forwards,  according  as  the  tumor  is  situated  in  front  of 
the  cervix  or  behind  it,  and  if  it  be  then  gently  and  carel'uUy 
turned  round,  we  shall  find  that  the  tumor,  previously  so  distinct, 
will  completely  disappear,  though  often  to  be  immediately  repro- 
duced with  the  same  character,  and  of  precisely  the  same  size  as 
before,  the  moment  that  the  instrument  is  withdrawn.  The  sound 
affords  at  the  same  time  the  opportunity  of  ascertaining  the  per- 
fect mobility  of  the  uterus,  and  the  absence  of  any  such  increase 
of  its  weight  as  the  existence  of  a  tumor  in  its  walls  must  of 
necessity  occasion. 

Valuable,  however,  as  is  this  means  of  diagnosis,  it  is  yet  not 
without  some  sources  of  fallacy,  while  its  emploj-ment  leads  occa- 
sionally to  no  satisfiictory  results.  The  instrument  will  sometimes 
not  pass  beyond  the  internal  os  uteri ;  and  though  pressure  upwards 
against  the  tumor,  so  as  to  lessen  the  bend  of  the  cervical  canal, 
not  infrequently  enables  us  to  introduce  it,  yet  this  is  not  always 
the  case  ;  and  I  need  not  say  that  force  is  never  allowable  in  order 
to  overcome  the  difficulty.  But  even  in  these  cases,  the  absence 
of  any  considerable  sense  of  weight  when  the  organ  is  poised  upon 
the  instrument  strengthens  the  presumption  against  the  existence 
of  any  uterine  tumor.  Further,  a  fibrous  tumor  projecting  into 
the  recto-vaginal  pouch  may  present  many  of  the  characters  of  the 
retroflected  womb,  while  tlie  fact  that  such  a  growth  not  infi-e- 
quently  flexes  the  organ,  and  causes  it  slightly  to  deviate  from  its 
natural  direction,  increases  the  probability  of  error.  ■  If,  too,  on 
turning  round  the  sound  after  its  introduction,  the  handle  of  the 
instrument  be  much  de])ressed,  its  other  end  will  of  course  be  cor- 
respondingly raised,  and  a  uterine  tumor  being  thus  carried  out 


180  DIAGNOSIS    OF 

of  easy  reacli  of  the  fingers,  may  apparently  disappear,  and  the 
case  be  thus  mistaken  for  one  of  simple  flexion  of  the  womb.  The 
safeguard  against  this  error  is  found  in  the  precaution  of  not  other- 
wise altering  the  position  of  the  sound,  when  the  instrument  is 
turned  round.  The  existence  of  adhesions,  indeed,  prevents  any 
attempt  at  replacing  the  flexed  womb  from  being  successful,  and 
thus  deprives  us  of  one  means  of  diagnosis,  though  even  in  such 
cases  the  direction  in  which  the  sound  enters  with  facility,  and  the 
fact  that  in  no  direction  but  that  one  will  it  enter  at  all,  are  not 
without  value.  Ovarian  tumors  are  almost  always  larger  and  more 
spherical  than  the  retroflected  fundus  uteri,  and  the  finger  will  in 
general  detect  the  body  of  the  uterus  driven  forwards  by  the  tumor, 
while  with  the  finger  of  one  hand  in  the  vagina,  and  the  other 
hand  over  the  pubes,  the  practitioner  will  in  general  be  able  to 
satisfy  himself  as  to  the  exact  relations  of  the  organ,  even  though 
attempts  to  introduce  the  sound  should  not  be  successful.  The 
same  statement  aUo  holds  good  with  reference  to  uterine  hsemato- 
cele,  and  further,  the  tumor  which  it  produces  does  not  usually 
present  the  same  degree  of  resistance  as  the  retroflected  uterus. 
One  of  the  largest  uterine  hsematoceles,  however,  which  has  ever 
come  under  my  notice  had  produced  complete  retroversion  of  the 
organ,  and  thus  rendered  diagnosis  very  difficult.  In  such  a  case, 
and  indeed  in  others  where  tumors  have  flexed  the  womb,  or  have 
much  altered  its  position,  the  risks  of  error  are  very  great  indeed. 
I  do  not  mean  to  claim  for  the  sound  the  advantage  of  always 
enabling  us  to  come  to  a  correct  conclusion,  but  only  to  express 
my  conviction  that  it  is  a  very  valuable  help  to  diagnosis,  and  that 
it  restricts  the  doubtful  cases  within  very  narrow  limits,  and  enables 
us  in  the  great  majority  of  instances  to  express  ourselves  at  once 
and  positively  with  reference  to  questions  which  otherwise  would 
often  be  very  obscure. 

Lastly,  we  come  to  the  consideration  of  the  appropriate  treatment 
of  these  misplacements;  a  question  which  has  received  two  difl'er- 
ent  answers,  according  as  practitioners  have  confijied  themselves 
to  the  endeavor  to  remove  those  ailments  with  which  the  malpo- 
sition was  associated,  and  to  which  the  symptoms  appeared  to  be 
directly  due ;  or,  as  they  have  aimed  at  something  more,  and  have 
attempted  to  restore  the  uterus  to  its  right  position,  and  to  maintain 
it  there  by  mechanical  contrivances.  Of  the  continental  writers 
who  first  called  special  attention  to  these  misplacements  of  the 
womb,  Schweighauser  contented  himself  with  the  employment  of 
remedies  calculated  to  remove  the  constipation,  and  to  relieve  the 
congestion  of  the  pelvic  viscera,  and  states,  that  having  accom- 
plished these  objects  he  found  that  the  uterus  returned  invariably 
to  its  proper  position  ;  and  Schmitt  also  coincided,  in  the  main,  in 
the  same  opinion.  A  view,  in  many  respects  similar,  has  been 
ably  aidvocated  by  Dr.  Oldham,^  who  regards  the  misplacement  of 
the  womb  as  being  invariably  the  secondary  consequence  of  its 

1  Guy's  Hospital  Rejwrts,  second  series,  vol.  vi. 


FLEXIONS  OF  THE  UTERUS.  181 

enlare^ement,  and  insists  on  the  special  advantages  of  the  use  of 
the  hichloride  of  mercury  in  removing  this  condition.  Schmitt 
attempts  in  his  essay  to  discriminate  hetween  cases  of  primary 
misphicement  of  tlie  womb,  and  those  in  which  its  altered  position 
is  secondary  to  some  enlargement,  or  to  some  inflammatory  affec- 
tion of  the  organ.  He  never  employs  any  means  for  the  purpose 
of  replacing  the  womb  so  long  as  either  constitutional  disturbance 
or  local  tenderness  of  the  uterus  is  present,  and  recognizes  the 
frequency  of  spontaneous  re]>lacement  of  the  womb  after  their 
removal ;  for  accomplishing  which  he  trusts,  like  Schweighiiuser, 
chiefly  to  rest,  and  to  the  due  evacuation  of  the  intestinal  canal 
by  the  regular  administration  of  saline  aperients.  If  the  misplace- 
ment should  still  continue,  or  if  the  case  was  already  chronic  in 
character  at  the  time  of  its  coming  under  treatment,  he  apiiroves 
of  careful  attem})ts  being  made  to  replace  the  womb.  These  at- 
tempts consist  in  pressure  upon  the  fundus  with  the  finger  in  the 
vagina,  or  sometimes  in  the  rectum,  and  he  throws  out  the  sugges- 
tion that  possibly  in  some  instances  a  contrivance  employed  by 
Professor  Richter,  of  Moscow,'  for  replacing  the  womb  retroverted 
in  pregnancy,  may  be  of  service.  As  a  subsidiary  means  tending 
to  promote  the  replacement  of  the  organ,  Schmitt  further  recom- 
mends that  the  patient  should  lie  upon  her  side  with  the  hips 
raised,  an  attitude  to  be  changed  oidy  for  that  on  the  abdomen, 
and  that  she  should  carefully  avoid  lying  on  the  back;  recommen- 
dations, all  of  which  are  much  insisted  on  by  many  practitioners 
at  the  present  day,  who  place  their  patients  on  the  prone  couch  in 
every  case  of  retroversion  or  retroflexion  of  the  womb.  Lastly, 
whenever  the  disposition  to  retroversion  of  the  v»'omb  continues 
in  si»ite  of  treatment,  lie  employs  one  of  Levret's  disk  [lessaries, 
made  with  an  aperture  sufliciently  large  to  admit  of  its  embracing 
the  neck  of  the  womb  ;  following  in  this  Levret's  own  directions 
as  laid  down  in  his  pa[)er  on  anteversion  of  the  womb.^ 

This  essay  of  Schmitt's,  to  which  the  particulars  of  nine  cases 
are  appended,  and  which  is  even  at  the  present  day  by  far  the  most 
complete  and  most  valuable  contribution  to  our  knowledge  of  the 
subject,  continued  to  be  the  guide  of  practice  in  Germany  until  the 
publication  of  Dr.  Simpson's  ingenious  observations.  Dr.  Simp- 
son not  only  drew  attention  in  this  country  and  in  France  to  the 
frequency  of  these  misplacements,  which  had  previously  been  so 
much  underrated,  but  he  also  insisted  on  their  mechanical  rectifi- 
cation as  the  most  important  means  of  removing  their  symptoms, 
and  suggested  a  novel  contrivance  both  for  replacing  the  womb 
and  for  maintaining  it  in  its  position. 

His  first  proposal,  to  replace  the  womb  by  means  of  the  uterine 
sound  (an  instrument  which  owes  almost  all  its  practical  utility  to 

1  See  Kichler's  Synopsis  Praxis  Medico-ObHietricicp,  4to.,  Mosqua;,  1810,  plato  ii, 
p.  70,  for  a  description  of  this  instniinont,  which  was  composed  of  a  oiirvtd  stem 
of  wood,  terminated  by  a  kind  of  plufr,  wliich  was  covered  with  a  cushion,  and  was 
intended  to  answcsr  the  jturpose  of  a  loni;  and  strong  finger  in  replacing  the  womb. 

*  Already  referred  to  in  Journal  Ue  Medccine,  etc.,  p.  -80. 


182  FLEXIONS  OF  THE  UTERUS. 

the  alterations  wliicli  lie  lias  made  in  its  form),  seems  to  have  heen 
anticipated  by  Osiander  in  1808,^  who  describes  the  introduction 
of  a  slightly  curved  instrument  into  the  retroverted  Vonib,  by 
turning  w^liich  round,  the  fundus  uteri  was  at  once  restored  to  its 
proper  position.  Osiander's  suggestion,  however,  was  disregarded, 
and  his  facts  were  discredited  and  soon  forgotten.  Velpeau  claims^ 
the  invention  of  a  pessary  with  a  somewhat  elastic  stem  projecting 
from  the  centre  of  a  semicircular  disk.  The  disk  being  turned 
forwards  in  cases  of  retroversion,  and  backwards  in  cases  of  the 
opposite  kind  of  misplacement,  the  tendency  of  the  elastic  stem 
would  be  gradually  to  restore  the  womb  to  its  proper  position, 
and  gently  to  maintain  it  there.  His  trials,  appear,  however,  by 
his  own  admission,  to  have  been  but  few,  and  their  results  were 
not  encouraging. 

Dr.  Simpson,  believing  that  in  the  great  majority  of  instances 
the  symptoms  associated  with  misplacement  of  the  womb,  and  also 
the  changes  which  the  organ  may  present,  are  mainly  dependent 
on  its  malposition,  insists  on  the  reposition  of  the  womb,  and  on 
the  employment  of  mechanical  means  to  secure  its  continuing  in 
its  place.  He  proposes  to  accomplish  the  first  object  by  means  of 
the  uterine  sound,  and  the  second  by  means  of  a  wire  stem  intro- 
duced into  the  cavity  of  the  womb,  and  maintained  there  by 
suitable  contrivances.  This  instrument  underwent  several  altera- 
tions in  Dr.  Simpson's  hands,  and  although  it  has  since  been 
modified  by  the  late  Professor  Kiwisch  of  Prague,  yet  Simpson's 
uterine  supporter,  with  the  improvements  devised  by  M.  Valleix, 
of  Paris,  appears  to  me  to  be  by  far  the  safest,  and  the  best 
adapted  for  its  purpose. 

Dr.  Simpson's  paper  was  not  accompanied  by  any  detail  of  cases, 
and  contained  scarcely  any  hint  as  to  possible  dangers  or  difi&culties 
in  the  employment  of  his  instrument.  The  attention  of  practi- 
tioners in  this  country  had  been  called  by  him  to  an  ailment,  the 
possible  occurrence  of  which  they  had  previously  scarcely  recog- 
nized, while  the  simplicity  and  ingenuity  of  his  proposed  means  of 
cure  recommended  it  to  almost  universal  adoption.  Some  doubts, 
indeed,  were  expressed  on  theoretical  grounds,  as  to  the  probable 
result  of  maintaining  a  foreign  body  for  weeks  or  months  together 
in  the  uterine  cavity.  These  were,  however,  silenced  for  a  time  by 
the  detail  of  cases  by  different  writers,  in  which  the  instrument 
was  worn  for  a  long  period,  not  only  without  injury,  but  with  very 
obvious  advantage.  Still,  by  degrees,  unfavorable  results  began 
to  be  more  generally  heard  of ;  much  uterine  pain,  almost  constant 
leucorrhoea,  associated  with  a  distressing  sense  of  pruritus;  menor- 
rhagia,  and  hemorrhage  between  the  menstrual  periods,  were  found 
to  be  of  no  very  rare  occurrence.  The  advocates  of  the  mechanical 
treatment  of  these  ailments,  too,  became  in  time  impressed  with 

1  Med.  Chir.  Zeiiung,  1808,  vol.  iv,  p.  170,  as  quoted  in  a  note  at  p.  54  of  Sclimitt, 
op.  cit. 

2  Lib.  cit.  p.  102. 


OBJECTIONS    TO    THE     UTERINE    SUPPORTER.  183 

the  necessity  for  greater  caution.  They  not  only  removed  the  in- 
strument at  the  menstruiil  periods,  which  at  first  they  were  not 
accustomed  to  do,  but  tried  to  liabituate  the  womb  by  degrees  to 
its  ])resence,  introchicing  it  at  first  for  an  hour  or  an  lionr  and  a 
half  at  a  time,  while  some  even  recommended  that  it  should  on  no 
occasion  be  allowed  to  remain  longer  than  three  or  four  hours 
within  the  womb.  Inconveniences  such  as  these,  the  incomplete- 
ness of  the  patient's  temporary  recovery  in  some  instances,  the 
fre(iuency  of  her  relapse  in  many  more,  the  occurrence  of  serious 
inflammation  of  the  wojub,  or  of  dangerous  peritonitis,  and  some 
instances  of  death  from  the  use  of  the  instrument,  have  now  led 
to  its  almost  universal  discontinuance. 

It  is  probable  that  in  a  few  years  more  the  uterine  supporter 
and  its  uses  will  have  become  mere  matter  of  history.  It  would 
not,  however,  be  right  at  present  merely  to  condemn  it  without 
at  the  same  time  assigning  the  reasons  which  appear  to  have  led 
most  practitioners  to  abandon  it. 

1st.  The  safe  employment  of  the  instrument  requires  that,  as  a 
general  rule,  its  use  should  be  continued  for  only  a  very  few  hours 
at  a  time ;  a  necessity  which  implies  that  every  woman  who  is 
submitted  to  this  mode  of  treatment  shall  undergo  two  vaginal 
examinations  every  day,  the  one  for  the  introduction  of  the  instru- 
ment and  the  other  for  its  withdrawal. 

2d.  The  quietude  which  its  use  imposes,  and  the  restriction  to 
which  the  patient  is  compelled  to  submit  in  order  to  avoid  severe 
sufiering  and  the  risk  of  serious  danger,  are  at  least  as  absolute  in 
their  kind  and  as  irksome  to  be  borne  as  those  which  any  other 
mode  of  treatment  involves,  while  it  is  necessary  to  continue  them 
for  a*s  long  a  time. 

8(1.  In  spite  of  all  precautions,  the  treatment  is  generally  painful, 
often  dangerous,  sometimes  fatal ;  and  the  untoward  accidents  have 
not  been  by  any  means  constantly  attributable  to  want  of  prudence 
cither  on  the  part  of  the  practitioner  or  of  his  patient. 

4th.  Cure,  even  by  the  long-continued  employment  of  this  means 
for  several  months,  is  uncertain,  while  relapses  are  very  frequent 
after  the  mechanical  support  is  discontinued  ;  besides  which  the 
permanent  cure  of  the  misplacement  is  far  from  being  always 
followed  by  the  cessation  of  the  symptoms.' 

^  To  meet  assertions  by  mere  counter-stntement  is  invidious,  and  carries  no 
convictions  to  those  whose  opinions  difter  from  our  own.  I  will  therefore  adduce 
here  the  testimony  of  two  men  wliose  position  and  character  entitle  their  opinion 
to  especial  weiejht. 

In  the  discussion  before  the  Academy  of  Medicine  at  Paris,  M.  Dubois  stated 
that  he  had  himself  treated  more  than  twenty  patients  by  means  of  the  uterine 
supporter,  which  in  some  instances  vv.'is  worn  for  several  months,  but  tiiat  the 
misjilacf'ment  re|)r(>duci>d  itself  within  a  very  short  time  after  the  removal  of  the 
instrument;  and  that  hr.  had  mach;  a  similar  ohservatioti  in  tlie  cast?  of  many 
patients  who,  havinuj  been  thus  treated  by  31.  Valleix  antl  Dr.  Simpson,  had  been 
dismissed  by  those  ejenthmien  as  cured. 

Professor  Scanzoni,  in  a  note  appended  to  the  fourth  edition  of  Kiwisch's  work 
on  the  Dlfseases  of  Women,  which  he  edited  after  the  author's  death,  makes  thcfol- 
lowini^  statement : 

"  The  observation  of  fifty-six  cases  of  flexion  of  the  uterus  during  the  past  four 


184  TREATMENT    OF 

On  these  accounts,  though  I  have  tried  the  uterine  supporter 
in  a  few  cases,  I  have  now  for  some  time  quite  given  up  its  em- 
ployment, and  content  myself  with  a  mode  of  treatment,  which, 
though  it  seems  to  promise  less,  yet  almost  always  affords  great 
relief,  while  in  a  large  number  of  instances  it  quite  removes  the 
patient's  sufferings,  and  is  not  infrequently  followed  by  the  com- 
plete rectification  of  the  position  of  the  womb.  I  believe,  too, 
that  even  they  who  were  the  most  strenuous  advocates  of  the 
uterine  supporter  in  this  country  have  silently  almost  renounced 
its  use ;  and  M.  Aran^  states  that  M.  Valleix,  who  strove  with  so 
much  abilit}'  to  introduce  it  in  France,  ''  had  towards  the  close  of 
his  life,  almost  completely  abandoned  its  employment,  substituting 
for  it  the  replacement  of  the  womb  with  the  uterine  sound,  fol- 
lowed by  the  introduction  of  an  air  pessary  either  in  front  of  the 
womb  or  behind  it,  according  to  the  direction  in  which  the  flexion 
had  taken  place." 

The  principle  upon  which  I  act  in  the  management  of  these 
cases  amounts  pretty  much  to  this  :  that  to  the  best  of  my  power 
I  take  care  of  the  general  symptoms,  and  leave  the  misplacement 
to  take  care  of  itself.  In  a  very  large  number  of  instances  the 
misplacement  succeeds  to  delivery  or  to  miscarriage,  and  the  womb 
is,  as  might  be  anticipated,  in  a  state  of  imperfect  involution.  In 
these  circumstances  rest  for  a  season  in  bed  or  on  a  couch,  occa- 
sional leeching  if  there  be  much  tenderness  of  the  organ,  and  the 
strictest  attention  to  the  condition  of  the  bowels,  which  should  be 
kept  freely  open  by  moderate  doses  of  saline  ap*erients,  seldom  fail 
speedily  to  relieve  the  congestion  of  the  womb  and  of  the  pelvic 
vessels,  and  to  place  the  organ  in  the  most  favorable  condition  for 
the  accomplishment  of  those  processes  by  which  its  bulk  may  be 
reduced.  With  the  approach  of  each  menstrual  period,  precau- 
tions should  be  redoubled,  for  menstruation  is  very  often  excessive 
in  quantity,  and  also  irregular  and  over-frequent  in  its  return  ; 
anticipating  the  proper  time  of  its  reappearance,  and,  moreover, 
after  its  apparent  cessation  coming  on  again  causelessly  or  on  the 
slightest  occasion.  In  proportion  as  this  evil  is  chronic,  may  we 
use  more  decided  means  to  check  it.  The  sulphuric  acid  and 
sulphate  of  magnesia  if  the  bowels  be  at  all  constipated,  the  sul- 
phate of  alum  if  that  condition  do  not  exist,  or  the  gallic  acid  or 
infusion  of  matico,  rnay  be  given  internally,  accompanied,  if  there 

years  compels  me  to  express  my  decided  conviction  that  the  mechanical  treatment 
of  this  affection  so  elaborately  set  forth  by  the  author  is  either  useless  or  positively 
mischievous."  After  adducing  some  reasons  for  this  opinion,  he  concludes:  "I 
will  merely  add,  that  since  I  have  quite  discontinued  leaving  the  sound  in  the 
uterus,  emploj'ing  the  uterine  supporter,  and  so  on,  and  have  contented  myself 
with  the  use  of  cold  vaginal  injections,  with  the  antiphlogistic  treatment  of  any 
chronic  uterine  inflammation,  and  the  application  of  caustic  to  any  ulceration  of 
the  OS  uteri,  and  with  the  endeavor  to  remove  the  chlorotic  symptoms  which  are 
seldom  absent,  I  have  been  much  better  satisfied  with  the  results  of  my  treatment 
than  I  was  at  the  time  when  I  allowed  myself  to  be  seduced  into  the  application 
of  a  variety  of  mechanical  contrivances." — Op.  ci^.,  vol.  i,  pp.  135,  136. 
1  Op.  cit,  1015. 


UTERINE    FLEXIONS.  185 

be  niueli  pain,  with  the  tincture  of  henbane,  or  of  Indian  hemp, 
neither  of  which  has  the  same  tendency  as  opium  to  produce 
coiistii)ation.  Cold  enemata  twice  a  day  may  be  employed  after 
the  second  or  third  day  of  the  discharge,  and  in  more  ol)fetinate 
cases,  even  vaginal  injections  of  matico  or  alum.  I  have  not, 
however,  ventured  upon  those  intra-utcrine  injections  or  cauteriz- 
ations of  the  inner  surface  of  the  womb  Avhich  Kiwisch  sometimes 
resorted  to,  both  during  the  presence  of  the  catamenia  and  also  in 
the  intervals  between  their  flov/. 

In  almost  all  cases  of  these  ailments,  a  state  of  general  debility, 
often  of  very  considerable  anajmia,  is  present,  and  chalybeate 
remedies  are  therefore  nearly  always  of  service.  As  a  general 
rule,  there  is  none  more  suitable  than  the  combination  of  iron  with 
an  aperient  salt,  which  I  recommended  to  you  when  speaking  of 
the  management  of  cases  of  menorrhagia.^  It  is  obvious,  however, 
that  3'our  prescriptions  may  here,  as  in  other  cases,  require  to  be 
varied  according  to  the  idiosyncrasies  of  your  patient  or  the  pecu- 
liarities of  her  case. 

After  the  general  uterine  tenderness  has  been  diminished  if 
necessary  by  previous  leeching,  recourse  may  be  had  with  advan- 
tage to  the  cold  douche,  which  both  restrains  hemorrhage  and 
leucorrhoea,  lessens  congestion,  and  tends  to  bring  about  contrac- 
tion of  the  lax  tissues  of  the  enlarged  womb.  Sometimes,  how- 
ever, the  douche  occasions  pain  ;  and  Avhen  this  is  the  case,  the 
cold  hip-bath,  cold  sponging  of  the  loins,  and  cold  vaginal  injec- 
tions may  be  substituted  for  it,  since,  though  less  efficacious,  they 
exert  a  similar  influence. 

Pain,  referred  to  one  or  other  ovarian  region,  and  varying  in 
severity  much  and  causelessly,  is  a  very  frequent  attendant  on 
these  malpositions  of  the  womb.  It  is  generally  much  relieved 
by  counter-irritation,  by  means  either  of  small  blisters  not  kept 
on  for  a  sufficiently  long  time  to  produce  vesication,  by  the  em- 
ployment of  a  croton  oil  liniment,  which  must  be  applied  by 
means  of  a  piece  of  sponge,  not  rubbed  into  the  part ;  or  by  the 
use,  if  the  skin  be  very  irritable,  of  the  milder  liniment  of  aconite 
and  belladonna.^ 

As  in  the  course  of  other  uterine  ailments,  so  in  these,  there 
are  occasional  attacks  of  violent  paroxysmal  pain,  which,  though 
not  limited  in  their  occurrence  to  the  menstrual  periods,  are  more 
apt  to  come  on  at  those  times,  and  sometimes  call  for  immediate 
relief.  The  local  application  of  chloroform  often  gives  ease  ;  and 
the  mitigation  of  suticring  which  it  jtrocures  frequently  continues. 
I  have,  however,  in  a  few  instances,  known  the  j»ain  to  be  more 
severe  and  more  lasting  than  tiie  remedy  so  ajiplicd  could  remove; 
and  when  that  is  the  case,  its  present  intensity  may  be  relieved  by 
inlialation  of  chloroform,  and  its  return  prevented  or  mitigated 
by  the  occasional  use  of  opiate  enemata,  or  by  the  administration 
of  camphor  and  morphia,  or  camphor  and  bellatlonna,  which 

1  See  Forinula  No.  1,  p.  4G.  *    See  Formula  No.  10,  p.  TJl. 


186     TREATMENT  OF  FLEXIONS  OF  THE  UTERUS. 

last  remedy,  though  somewhat  uncertain,  is  often  of  very  great 
utility. 

But  you  may  inquire  whether  in  these  cases  I  reject  not  only 
the  use  of  permanent  mechanical  supports  for  the  uterus,  but  also 
the  employment  of  mechanical  means  for  its  replacement?  Now, 
I  believe  that,  with  the  exception  of  those  rare  instances  in  which 
the  misplacement  is  the  result  of  some  sudden  shock  or  violence, 
mechanical  interference  is  rarely  desirable ;  and  that  the  womb 
will  of  its  own  accord  gradually  revert  to  its  proper  position,  or, 
continuing  misplaced,  will  cease,  when  its  attendant  ailments  liave 
been  removed,  to  give  rise  by  its  mere  misplacement  to  any  incon- 
venience. While,  therefore,  I  use  the  sound  as  a  means,  and  I 
believe  a  very  valuable  means,  of  diagnosis,  I  do  not  resort  to  that 
frequent  replacement  of  the  organ  by  it  which  has  been  adopted 
by  some  practitioners,  who  yet  hesitate  to  leave  any  kind  of  sup- 
port permanently  within  tlie  uterus.  I  do  not  follow  this  plan, 
because,  while  suffering  occasionally  remains  for  a  considerable 
time  after  the  introduction  of  the  instrument,  the  womb  almost 
invarial)ly  ftills  back  again  to  its  previous  unnatural  position  alter 
its  withdrawal. 

There  has  been  much  debate  about  the  use  of  pessaries  in  these 
cases,  since,  while  still  employed  by  some  practitioners,  they  are 
decried  as  altogether  unserviceable  by  others,  and  chiefly  by  the 
advocates  of  the  intra-uterine  supporter.  It  must  be  confessed 
that  they  are  very  imperfect  means  of  support;  but,  nevertheless, 
I  have  seen  much  relief  from  their  employment  in  cases  of  retro- 
flexion and  retroversion  of  the  womb.  They  serve  to  keep  the 
uterus  comparatively  fixed  in  the  pelvis,  and  spare  it  from  many 
of  the  painful  shocks  to  which  the  organ  is  otherwise  almost 
unavoidably  exposed  when  the  patient  begins  to  move  about, 
and  especially  when  she  sits.  They  moreover  diminish,  in  many 
instances,  the  painful  straining  eftbrts  at  defecation ;  a  fact  which 
shows  how  much  more  that  ailment  partakes  of  a  neuralgic  char- 
acter than  of  that  of  a  disorder  due  to  mechanical  causes.  The 
kind  of  pessary  which  has  seemed  to  me  usually  most  serviceable 
is  one  of  Indian-rubber,  of  an  oval  form,  inflated  with  air,  which, 
being  introduced  in  the  cul-de-sac  between  the  uterus  and  the 
rectum,  serves  to  support  and  to  keep  steady  the  fundus  of  the 
womb.  The  recent  employment  of  vulcanized  Indian-rubber  and 
gutta  percha  for  these  purposes,  and  the  various  modifications  of 
these  instruments  which  the  new  materials  have  rendered  possible, 
may  probably  lead  to  the  invention  of  some  useful  varieties  of 
pessary  adapted  to  the  peculiarities  of  difl:erent  cases.  One  of 
these  I  must  mention,  since  it  acts  on  a  difl'erent  principle  from 
others,  and  promises,  as  far  as  my  limited  experience  of  it  at 
present  enables  me  to  judge,  to  be  very  serviceable  in  some  cases 
of  retroversion  or  retroflexion  of  the  womb.  The  idea  of  the 
instrument  is,  that  misplacement  of  the  womb  may  be  corrected 
by  affording  support  to  the  vaginal  wall,  and  thus  rendering  it 
unyielding.    Under  the  name  of  the  lever  pessary,  it  was,  I  believe, 


INVERSION    OF    THE     UTERUS.  187 

first  suggested  by  Dr.  Hodge  of  Philadelphia  ;^  but  a  preferable 
form  a|)pears  to  me  to  be  that  devised  by  my  friend  Dr.  Priestley, 
and  which  may  be  obtained  of  all  instrument-makers.  It  consists 
of  a  frame  of  gutta  percha,  of  the  tliickness  of  an  ordinary  goose- 
qnill,  or  a  little  thicker,  about  five  inches  long,  twisted  into  some- 
what of  a  fiddle  shape,  its  upper  end  about  an  inch  and  a  half 
broad,  its  two  limbs  approaching  till  they  unite  in  a  sort  of  button, 
and  the  whole  instrument  having  a  gentle  curve  like  that  of  an 
italic  /.  The  instrument  is  introduced  with  its  broad  end  in  the 
cul-de-sac  between  the  uterus  and  rectum ;  while  to  the  button  at 
the  otlier  end,  projecting  beyond  the  vulva,  are  attached  four 
vulcanized  Indian-rubber  straps,  which  are  fastened  to  a  belt  that 
surrounds  the  abdomen.  These  straps,  indeed,  are  by  no  means 
constantly  necessary;  and  I  have  found  the  pessary,  when  em- 
ployed without  them,  sometimes  keep  in  its  position  very  well, 
and  aflbrd  great  comfort  to  the  wearer. 


LECTURE    XIII. 

MISPLACEMENTS  OF  THE  UTEKUS. 

Inversion  of  the  Uterus,  generally  occurs  during  labor  ;  sometimes  spontane- 
oush';  symptoms  usually  very  formidable.  Its  ebronic  form ;  tendency  of  it 
to  destroy  life;  occasional  exceptions  to  this  rule;  alleged  spontaneous  replace- 
ment of  uterus.  Diagnosis,  and  management  of  accident  when  recent;  state 
of  womb  modifies  chances  of  replacement,  which  are  very  small,  except  when 
attom]it(d  immediately. 

Chronic  Inversion,  its  management;  extirpation  of  uterus  ;  causes  modifying  suc- 
cess of  operation.  Errors  of  diagnosis,  how  to  avoid  them  ;  further  cautions 
as  to  best  mode  of  operating. 

Inversion  from  Polypus.     Practical  cautions  respecting  it. 

Ascent  of  Uterus  ;  its  various  causes  and  diagnostic  value. 

Those  forms  of  uterine  misplacement  to  which  our  attention 
has  hitherto  been  directed,  claimed  our  notice  as  much  from  the 
frequency  of  their  occurrence  as  from  the  importance  of  their 
symptoms.  We  found  them  to  be  the  occasion  of  discomfort  of 
various  kinds,  and  not  seldom  the  exciting  cause  of  much  dis- 
turbance of  the  uterine  functions;  but  in  scarcely  any  instance 
were  they  of  themselves  dangerous  to  life,  while  they  moreover 
always  admitted  of  much  palliation,  often  indeed  of  complete  cure. 

We  have  now,  however,  to  turn  to  the  study  of  a  form  of  uterine 
misplacement,  which,  though,  happily  of  very  rare  occiirronee,  is 
one  of  the  most  grievous  accidents  which  can  befall  a  woman,  inas- 
much as  its  almost  invarial)le  tendency  is  to  destroy  life,  while  the 
remedy  to  which  alone  we  can  resort  in  the  greater  number  of 
cases  for  its  cure  is  an  operation  of  a  most  hazardous  kind,  one 

1  On  Diseases  Peculiar  to  Women,  8vo.,  Philndelphia,  18G0,  p.  830. 


188  SYMPTOMS    OF 

wliicli  mutilates  the  patient,  and  renders  her  forever  incapable  of 
performing  the  functions  of  her  sex. 

Inversion  of  the  uterus,  the  turning  of  the  organ  inside  out,  is  an 
accident  clearly  impossible  in  the  natural  condition  of  the  nnim- 
pregnated  womb ;  it  being  obviously  essential  for  its  occurrence 
that  the  organ  should  have  attained  a  certain  size,  and  that  its 
walls  should  be  comparatively  yielding.  It  is  indeed  only  at  an 
advanced  period  of  pregnancy  that  these  conditions  are  generally 
met  with,  and  only  during  labor  that  an  exciting  cause  is  likely 
to  be  superadded  capable  of  producing  the  misplacement ;  but  at 
that  time  violent  traction  at  the  funis  by  some  unskilled  practi- 
tioner, before  the  detachment  of  the  placenta,  may  mechanically 
invert  the  womb,  or  the  organ  may  by  its  own  contractions  invert 
itself,  just  as  the  intestine  does  in  cases  of  intussusception.  The 
late  Mr.  Crosse  of  Norwich,  in  his  v^ry  elaborate  Esmy  on  Inver- 
sion of  the  Uterus^  which  unhappily  he  did  not  live  to  complete, 
states^  that  in  350  out  of  400  cases  of  inverted  uterus  of  which  he 
had  found  mention,  the  accident  occurred  as  a  consequence  of  par- 
turition ;  and  there  can,  I  think,  be  no  doubt  but  that  the  real 
proportion  of  cases  in  which  it  is  traceable  to  this  cause  is  much 
higher  than  seven  to  one.  Of  the  remaining  fifty  cases,  forty  were 
said  to,  have  occurred  in  connection  with  the  presence  of  a  polypus 
in  the  interior  of  the  womb,  the  accident  sometimes  taking  place 
spontaneously,  in  other  instances  resulting  from  traction  at  the 
outgrowth  in  some  attempt  to  accomplish  its  removal. 

Almost  all  of  those  rare  cases  in  which  the  uterus  is  alleged  to 
have  become  inverted  independently  of  either  of  the  above  causes, 
are  deficient  in  such  details  as  are  needed  to  substantiate  their 
correctness,  and  doubt  may  be  reasonably  entertained  with  refer- 
ence either  to  the  accuracy  of  the  diagnosis,  or  else  as  to  the  truth- 
fulness of  the  history  related  by  the  patient.^  Enlargement  of  the 
uterine  cavity,  however,  associated  with  some  cause  capable  of 
exciting  contraction  of  its  fibres,  may  be  looked  on  as  the  two 
conditions  essential  to  the  inversion  of  the  organ  ;  and  where 
these  two  coexist,  as  in  Dr.  Thatcher's  case  of  enlargement  of  the 
womb  from  hydatids,^  there  the  possibility  of  inversion  taking 
place  must  be  conceded. 

ISo  instance  has  come  under  my  own  observation  of  uterine 
inversion  in  the  recent  state,  and  indeed  the  annals  of  the  Dublin 
Lying-in  Hospital  and  those  of  the  London  Maternity  Charity 
sufliciently  illustrate  the  rarity  of  the  accident,  since  it  was  not 

1  Part  ii,  p.  70. 

^  Baudelocque's  remarkable  case  of  alleged  inversion  of  the  womb  in  a  girl 
fifteen  years  old,  who  suifered  from  menorrhagia,  appears  to  me  to  be  one  in  which 
"We  may  be  allowed  to  entertain  some  doubt  as  to  the  accuracy  of  the  diagnosis ; 
while  nothing  can  be  vaguer  than  the  history  of  Lisfranc's  patient  [Clinique 
Chirurgicale,  vol.  iii,  p.  380),  whose  symptoms  are  said  to  have  existed  five  years 
before  she  came  under  his  observation. 

3  As  narrated  in  Crosse's  Essay,  part  i,  p.  57. 


INVERSION    OF    THE    UTERUS.  189 

once  met  with  in  a  total  of  more  than  140,000  labors/  Its  symp- 
toms, as  detailed  in  works  on  midwifery,  are  so  appalling  and  so 
characteristic,  that  it  would  seem  almost  impossible  either  to  over- 
look or  to  misinterpret  them.  Sudden  collaj^se,  accompanying 
abundant  hemorrhage,  associated  with  disappearance  of  the  tumor 
formed  by  the  uterus  in  the  abdomen,  and  the  presence  of  a  large 
spherical  body  either  just  within  the  vagina,  or  projecting  beyond 
the  external  parts,  are  the  ordinary  indications  of  the  womb  having 
been  inverted;  and  the  occurrence  even  of  some  of  these  accidents 
in  the  third  stage  of  labor,  or  just  after  the  detachment  of  the 
placenta,  ought  at  once  to  excite  the  suspicions  of  the  attendant 
with  reference  to  their  almost  invariable  cause. 

In  spite  of  this,  however,  in  a  very  large  proportion  of  instances 
in  which  inversion  of  the  uterus  in  the  chronic  state  has  come  under 
observation,  the  accident,  though  clearly  tracea])le  to  delivery,  has 
been  overlooked  at  the  time  of  its  occurrence,  and  almost  the  only 
opportunity  of  replacing  the  womb  has  thus  been  lost.  Three 
cases  of  inversion  of  the  uterus  in  the  chronic  state  have  come 
under  my  own  observation  ;  but  in  none  of  them  was  the  condi- 
tion discovered  until  some  months  after  the  patient's  delivery. 
The  history  given  of  herself  by  one  of  these  patients,  who  fourteen 
months  after  her  delivery  was  admitted  under  my  care  into  St. 
Bartholomew's  Hospital,  was,  that  the  detachment  of  the  placenta, 
which  she  believed  was  eftected  by  the  hand,  was  accompanied  by 
hemorrhage  so  profuse  as  to  occasion  syncope ;  and  she  was  told 
by  the  nurse  that  the  womb  was  brought  down  and  projected  ex- 
ternally, but  was  apparently  replaced  by  the  gentleman  in  attend- 
ance. Nothing  furtlier  of  any  consequence  transpired  for  a  week 
from  this  time,  when  on  sitting  up  to  have  a  motion  the  body 
again  projected  externally,  but  was  once  more  replaced  by  the 
nurse,  since  which  time  it  had  never  again  protruded  beyond  the 
vulva.  In  the  case  of  the  second  patient  the  placenta  was  removed 
by  hand ;  and  after  a  period  of  insensibility,  which  lasted  for  two 
days,  inflammatory  symptoms  came  on,  but  no  circumstance 
awakened  suspicion  as  to  the  existence  of  inversion  of  the  uterus. 
In  the  third  case  the  placenta  came  away  spontaneously;  the 
hemorrhage  does  not  appear  to  have  been  very  profuse;  and 
severe  expulsive  pain  was  the  most  prominent  symptom  for  the 
first  two  months  after  the  patient's  delivery.  In  other  instances 
there  have  been  even  fewer  symptoms  to  engage  attention,  and 
nothing  has  been  observed  except  some  hemorrhage  succeeding 
the  spontaneous  expulsion  of  the  placenta,  until  the  return  and 
the  persistence  of  the  bleeding  have  led  to  a  vaginal  examination 
and  to  the  discovery  of  the  then  almost  remediless  displacement 
of  the  womb.  In  these  cases  there  can  be  no  doubt  but  that  the 
uterus  has  inverted  itsolf,  and  that  this  accident  has  been  brought 
about,  not  by  simple  want  of  contractility  of  the  organ,  but  by 

'   Tlfirdy  and  IVIcClintock,  Prndirnl  Oharrraiions  in  ^^!lhl^!fr>•J/.  p.  223;  find  l?ains- 
bothfini,  Obstetric  Medicine,  «Scc.,  3d  od.,  p.  719. 


190  SYMPTOMS    OF 

the  irregular  and  unequal  contraction  of  its  different  parts;  a  state 
of  comparative  relaxation  of  the  os  and  cervix  coexisting  with  vio- 
lent action  of  its  fundus.^  The  only  circumstance,  indeed,  which 
tends  to  prevent  our  receiving  this  as  the  ordinary  explanation  of 
the  occurrence  of  inversion  of  the  womb  during  labor,  is  its  not 
happening  in  institutions  such  as  the  Dublin  Lying-in  Hospital,  in 
which  the  last  stage  of  labor  is  wisely  conducted;  while  spontane- 
ous inversion  of  the  organ  would  obviously  be  nearly  as  liable  to 
happen  among  patients  in  a  lying-in  hospital  as  elsewhere. 

Profound  shock  to  the  nervous  system  and  profuse  hemorrhage 
are,  as  has  already  been  mentioned,  the  two  characteristic  symp- 
toms of  inversion  of  the  uterus.  Dr.  Radford  has  shown,  however, 
that  except  in  cases  where  the  placenta  was  still  partially  adherent 
to  the  womb,  the  hemorrhage  is  by  no  means  so  formidable  as 
might  beforehand  be  anticipated,  and  that  the  shock  to  the  sys- 
tem is  independent  to  a  great  degree  of  the  loss  of  blood.  If  these 
immediate  dangers  are  surmounted,  the  patient's  subsequent  his- 
tory seems  to  be  liable  to  considerable  variation  with  reference  to 
the  period  at  which  formidable  symptoms  reappear,  though  the 
symptoms  themselves  are  very  uniform  in  their  character.  The 
state  of  the  uterus,  too,  differs  in  a  way  which  greatly  modifies 
our  prognosis;  the  organ  remaining  in  some  instances  compara- 
tively soft  and  3'ielding,  admitting  of  being  indented  by  the  finger, 
and  consequently  allowing  of  attempts  at  its  replacement  being 
made  with  a  fair  prospect  of  success;  while  in  other  cases  it  be- 
comes at  once  small  and  firmly  contracted,  and  bids  defiance  to 
every  effort  to  rectify  its  position.  I  do  not  know  how  to  account 
for  these  difterences  in  the  state  of  the  womb,  though  their  im- 
mediate cause  must  consist  in  the  absence  of,  or  at  least  in  the 
very  imperfect  involution  of  the  organ  in  one  case,  and  the  rapid' 
and  complete  accomplisliment  of  it  in  another. 

Those  cases  where  the  uterus  remains  soft  and  flaccid,  and 
capable  of  replacement,  are,  however,  exceptions  to  the  general 
rule,  as  might,  indeed,  be  inferred  from  the  rarity  of  the  instances 
in  which,  after  many  days,  or  even  after  many  hours,  the  accident 
has  admitted  of  remedy.  In  the  majority  of  instances  the  con- 
traction of  the  uterus  occurs  very  speedily,  and  is  so  firm  that  the 
inverted  organ  has  sometimes  been  mistaken  for  the  head  of  a 
second  foetus,  while  the  processes  of  involution  usually  go  on  as 
completely  as  in  the  womb  when  in  its  natural  position.     This 

1  This  mode  of  production  of  inversion  of  the  womb  during  labor,  first  recog- 
nized by  Saxtorph,  Gesmnmelte  Schriften,  8vo.,  Kopenhagen,  1804,  p.  301,  has  been 
fully  and  ably  set  forth  by  Dr.  Kadford,  Dublin  Journal  for  1837,  Nos.  34  and  35; 
and  is  now  generally  received  as  a  frequent,  if  not  the  most  frequent,  mode  in 
which  it  is  brought  about.  Dr.  Simpson,  in  expressing  his  adhesion  to  Dr.  Kad- 
ford's  views — see  his  Obstetric  Works^  vol.  i,  p.  817 — refers  to  two  cases  in  which 
inversion  of  the  uterus,  with  expulsion  of  the  child,  took  place  after  the  mother's 
death.  Both  of  the  cases  are  very  marvellous.  Bcerner's  patient,  indeed,  had 
reached  the  full  period  of  pregnancy  ;  but  she  whose  history  is  very  imperfectly 
recorded  hx  Klaatsch,  was  only  in  the  fourth  month;  and  the  inversion  of  the 
womb  is  alleged  to  have  occurred  in  the  second  night  after  her  death.  One  is  at  a 
loss  as  to  the  inferences  to  be  drawn  from  histories  so  wonderful. 


INVERSION  OF  THE  UTERUS.  191 

fact  is  attested  by  the  numerous  preparations  of  chronic  inversion 
of  the  womb,  in  which,  as  in  one  in  the  Museum  of  St.  Bartho- 
lomew's Hospital,  the  organ  is  so  small  that  the  0})ening  of  the 
pouch  which  it  forms  would  not  admit  anything  larger  than  a 
quill,  while  its  dense  tissue  seems  at  first  scarcely  compatible 
with  the  outpouring  of  so  abundant  a  discharge  of  blood  as  that 
under  wliich  the  patient  sank. 

In  many  instances  hemorrhage  has  continued  to  flow  at  sliort 
but  uncertain  intervals  from  the  moment  of  the  occurrence  of  the 
accident,  but  to  this  there  are  occasional  exceptions.  In  one  of  the 
cases  wdiieh  came  under  my  observation,  a  very  slight  occasional 
discharge  of  blood  was  all  that  occurred  for  several  months  after 
the  patient's  delivery ;  she  having  suckled  her  child  for  thirteen 
months.  At  the  eleventh  month,  however,  the  ovaries  resumed 
their  function,  and  the  menses  were  extremely  profuse.  On  their 
next  return  the  bleeding  was  still  more  abundant,  and  thirteen 
months  after  delivery  the  flooding  w^as  alarming  from  its  quantity, 
and  w'as  intermingled  with  large  coagula,  which  were  discharged 
without  any  sufl'ering.  Even  before  the  hemorrhage  became  pro- 
fuse the  patient  sufl'ered  from  ordinary  leucorrhoeal  discharges, 
which  afterwards  continued  in  the  intervals  of  menstruation.  13y 
degrees  tlie  intervals  become  shorter,  the  hemorrhage  more  pro- 
fuse, and  the  leucorrhoeal  discharge  lost  its  character  of  a  mucous 
secretion,  and  became  more  serous.  At  last,  when  well-nigh 
drained  of  all  her  blood,  the  red  color  almost  completely  disap- 
peared from  the  discharges,  and  for  the  last  two  or  three  months 
of  her  life  there  was  a  constant  flow  of  serum,  but  the  positive 
hemorrhage  was  very  small.  A  sense  of  bearing  down,  and  the 
occasional  appearance  of  the  inverted  womb  externally  on  walk- 
ing or  any  exertion,  so  long  as  the  patient  was  able  to  follow  her 
usual  avocations,  were  her  only  other  symptoms,  and,  indeed,  the 
only  ones  which  are  common  in  these  cases.  There  are,  however, 
some  instances  in  which  the  inverted  womb,  from  hanging. exter- 
nally, has  been  exposed  to  injury,  and  become  ulcerated;  and 
others  in  which  the  violent  constriction  of  the  inverted  body  of 
the  womi)  by  the  os  uteri  has  produced  gangrene  of  tlie  organ. ^ 

Such  being  the  consequences  that  follow  the  inversion  of  the 
uterus  during  labor,  it  is  obvious  that  they  tend  of  necessity  to  a 
fatal  issue,  and  that  the  question  is  not  so  much  how,  as  how^  soon 
a  case  will  terminate.  Mr.  Crosse,^  whose  industry  has  thrown  so 
much  light  on  many  subjects  connected  with  this  accident,  states, 
that  in  seventy-two  out  of  one  hundred  and  nine  iiital  cases,  death 
took  place  within  a  few  hours,  in  eight  w'ithin  a  week,  and  in  six 
more  within  four  weeks.  Tlic  immediate  danger,  however,  being 
surmounted,  there  follows  during  lactation  an  interval  of  compara- 
tive safety  and  of  cessation  of  serious  symptoms,  which  reap})ear 

1  Sevi'ial  rcttTonces  to  this  occurrence  are  givuii  bv  Crosse,  o/j.  cjV.,  part  ii,  j..  Ill, 
Notes  104  and  1U5. 

2  Op.  clL,  }).  170. 


192  SPONTANEOUS    CURE    OF    INVERSION. 

when  snckling  is  over.  It  appears  that  of  the  remaining  twenty- 
three  patients  only  one  died  at  the  fifth  month,  and  then,  as  the 
result  of  an  operation  which  had  an  unsuccessful  issue,  one  died 
at  eight  months,  three  at  nine  months,  and  the  others  at  various 
periods  of  from  one  jenr  to  twenty  years. 

These  latter  cases  of  great  prolongation  of  life,  in  spite  of  the 
persistence  of  inversion  of  the  womb,  lead  us  lastly  to  notice  those 
rare  instances  in  which  life  has  not  only  continued  for  many  years, 
but  in  which  serious  symptoms  have  been  altogether  absent.  Of 
these  the  most  remarkable  history  is  that  recorded  by  Boivin  and 
Dug^Sji  of  a  woman  who  was  brought  to  one  of  the  hospitals  at 
Paris  six  days  after  a  labor  in  which  her  womb  had  become 
inverted.  Repeated  eflbrts  were  made  by  M.  Dubois,  as  well  as  by 
Madame  Boivin  herself,  to  replace  the  womb,  but  without  success, 
and  no  symptoms  being  at  the  time  present,  the  patient  returned 
into  the  country  by  diligence  on  the  eighteenth  day  after  her 
delivery.  N^othing  more  was  heard  of  her  till  five  years  afterwards, 
when  she  presented  herself  to  Madame  Boivin,  with  her  uterus 
still  inverted,  though  of  smaller  size  than  before.  Some  sense  of 
dragging  at  the  groins,  a  frequent  desire  to  pass  water  when  she 
was  up  and  exerting  herself,  and  a  discharge  of  a  reddish  mucus 
recurring  every  fifteen  or  twenty  days  and  lasting  for  a  few  hours, 
were  the  only  symptoms  from  which  she  suffered.  She  was  in- 
commoded, however,  by  having  grown  enormously  fat,  and  ex- 
pressed anxiety  at  the  non-appearance  of  her  menses.  Two  cases 
are  related  by  Lisfranc;^  the  one  that  of  a  woman  who  died  at 
the  age  of  seventy  years,  of  inflammation  of  the  lungs ;  and  the 
other  that  of  a  person  forty-eight  years  okl,  whose  only  uterine 
symptoms  were  slight  leucorrhoea,  and  dragging  sensation  at  the 
loins,  and  whose  uterus,  on  her  death  from  enteritis,  was  also 
found  completely  inverted.  In  neither  of  these  cases,  indeed,  was 
there  any  satisfactoryhistory  of  the  manner  in  which  the  accident 
took  place;  but  the  existence  of  inversion  at  the  examination 
after  death,  and  the  absence  of  symptoms  of  it  during  the  lifetime 
of  the  patients,  are  both  clearly  substantiated,^ 

Stranger  still  than  the  above  are  cases  in  which  the  uterus  is 
alleged  to  have  spontaneously  replaced  itself.  The  possibility  of 
the  spontaneous  replacement  of  a  partial  inversion  of  the  w^omb 
during  labor  must  be  admitted,  and  can  even  be  understood ;  an 
occurrence  stated  by  Saxtorph^  to  have  taken  place  in  a  patient 
whose  uterus  he  endeavored  in  vain  to  replace ;  and  being  thus 
compelled  to  leave  the  case  to  nature,  the  organ  recovered  in  a  few 
days  its  natural  position.  But  there  are  other  instances  in  which 
spontaneous  replacement  of  the  completely  inverted  womb  is  stated 
to  have  occurred  many  days,  or  even  months  or  years,  after  de- 
livery.    It  is  difficult  to  know  what  opinion  to  form  concerning 

»  Op.  cit,  vol.  i,  p.  245.  2  Qp.  cit  ,  vol.  ii,  pp.  379-383. 

3  References  to  other  similar  cases  are  given  by  Meissner,  op.  cit.,  vol.  i,  p.  743. 

<  Gesammelte  Schriften,  8vo.,  Kopenhagen,  1804,  p.  307. 


DIAGNOSIS     OF    RECENT    INVERSION.  193 

these  cases;  in  some  the  accuracy  of  the  diagnosis  appears  very 
doubtful,  and  in  others  the  details  given  are  far  too  meagre  to 
warrant  any  conclusion  with  reference  to  their  real  nature ;  while 
unquestionably  no  such  exceptional  occurrences  sliould  be  allowed 
to  influence  our  treatment  of  any  case  which  may  come  under 
our  care.^ 

Questions  of  obstetric  practice  do  not  fall  within  the  scope  of 
these  Lectures.  I  shall  therefore  say  very  little  with  reference  to 
the  management  of  these  misplacements  of  the  womb  in  their 
recent  state,  but  shall  pass  almost  at  once  to  the  consideration  of 
the  diagnosis  and  treatment  of  the  accident  in  its  chronic  form. 

In  the  recent  state  the  diagnosis  of  inversion  can  seldom  be 
obscure.  There  are  instances,  indeed,  in  which  it  has  been  over- 
looked or  mistaken,  or  in  which  the  inverted  uterus  has  even  been 
torn  away  under  the  supposition  that  it  was  the  placenta;  but 
such  errors  imply  a  depth  of  ignorance  and  folly,  upon  which  all 
rules  and  all  experience  would  alike  be  wasted.  There  seem,  how- 
ever, to  be  cases  where,  some  short  time  after  the  detachment  of 
the  placenta,  the  womb  has  become  of  its  own  accord  partially 
inverted,  or  depressed  at  its  fundus,  and  where,  while  much  de- 
pression and  some  hemorrhage  have  existed,  there  has  neither 
been  a  tumor  to  be  felt  per  vaginam,  nor  disappearance  of  that 
which  the  uterus  should  form  in  the  abdomen.  This  partial  in- 
version, too,  tends  to  increase,  so  that  the  depression  of  one  day 
may  amount  (to  borrow  Mr.  Crosse's  terminology)  to  introversion 
on  the  next  day,  and  to  complete  inversion  on  the  third.  I  do  not 
know  that  more  is  needed  to  preserve  from  this  error  than  a 
knowledge  of  the  possibility  of  falling  into  it,  and  of  the  conse- 
quent necessity  of  ascertaining  in  every  instance  where  causeless 
depression  and  causeless  bleeding  follow  the  last  stage  of  labor, 
not  only  that  the  uterine  tumor  still  remains  in  the  abdomen,  but 
also  that  it  retains  its  proper  size  and  contour. 

When  the  accident  does  occur  before  the  detachment'  of  the 
placenta,  the  whole  weight  of  evidence  is,  I  think,  in  favor  of  re- 
moving the  placenta  before  endeavoring  to  return  the  womb;  and 
the  non-occurrence  of  serious  bleeding  in  many  instances  of  recent 
inversion  of  tlie  womb  after  the  separation  of  the  placenta,  strongly 
corroborates  the  accuracy  of  the  views  as  to  the  source  of  hemor- 
rhage in  labor,  which,  though  so  clearly  explained  by  Dr.  Simp- 
son, have  been  much  misunderstood  and  misrepresented. 

There  is  some  discrepancy  between  the  directions  given  by 

1  The  most  satisfactory  of  those  cases  is  Dr.  Thatcher's,  referred  to  by  ^Ir.  Crosse, 
op.  cit.,  p.  170,  note.  But  in  tliis  instance  the  uterus  had  resumed  its  proper  posi- 
tion at  the  end  of  a  month.  The  ease  related  by  Dailliez,  .S'^r  le  /{runrKemrnt  de 
la  Matricc,  8vo.,  Pari.-;,  ]803,  p.  33,  corresponds  mueli  more  nearly  with  one  of 
polyjius  than  of  inversion  ;  and  of  Dr.  Meigs's  two  cases  the  former  is  very  <lcfioient 
in  detail;  while  with  reference  to  both  there  is  a  long  period  during  whi«'h  the 
patients  were  not  under  any  one's  observation — circumstances  that  must  diminish 
their  valuc!.  Sec  Meigs's  Translation  of  Colombat,  Diseasesof  Women,  8vo.,  I'hila- 
delj)hia,  1845,  p.  182. 

13 


194  REPLACEMENT    OF 

different  writers  for  the  replacement  of  the  uterus  when  inverted  dur- 
ing labor;  for  while  some  practitioners  recommend  the  endeavor 
to  indent  the  fundus  of  the  organ  with  the  fingers,  and  thus 
to  replace  first  that  part  which  was  first  inverted,  others  advise 
that  the  womb  should  be  grasped  between  the  fingers,  and  that 
while  thus  compressed  as  much  as  possible,  it  should  be  carried 
up  through  the  os  uteri  or  that  part  of  the  womb  ^vhich  represents 
it,  and  should  be  thus  restored  to  its  proper  position.  I  imagine 
that  these  different  rules  imply  the  existence  in  the  one  case  of  the 
soft  and  flaccid  condition  of  the  womb  ;  in  the  other,  of  a  state  of 
comparative  firmness  and  contraction  ;  and  that  according  as  the 
former  or  the  latter  state  is  present,  the  first  or  second  kind  of 
manipulation  may  be  advantageously  employed.  In  the  great  ma- 
jority of  instances  where  the  uterus  has  been  replaced  after  the 
lapse  of  some  considerable  time,  this  lax  state  of  the  uterus,  which 
must  greatly  facilitate  the  endeavor,  appears  to  have  still  persisted. 
Thus  in  a  case  related  by  Dr.  Borggreve,  and  referred  to  by 
Kiwisch,^  continued  pressure  by  means  of  a  long  pessary,  fastened 
externally  with  a  T  bandage,  reduced  the  uterus  in  three  days; 
its  employment  ha\ing  been  commenced  on  the  fourth  day  after 
delivery.  A  similar  contrivance  was  successful  in  Dr.  Smarts  case,^ 
the  uterus  having  already  been  inverted  three  Aveeks  wdien  it  was 
first  employed.  Dr.  White,  of  Butlalo,  U.  S.,^  reduced  the  uterus 
on  the  seventh  day,  and  Dr.  MendenhalP  on  the  sixteenth  day 
after  delivery,  by  manipulations  assisted  by  the  employment  of  a 
large  rectum  bougie,  the  patient  in  both  instances  being  partially 
under  the  influence  of  chloroform.  Dr.  White's  patient,  however, 
died  from  the  effects  of  the  previous  hemorrhage.  In  Dr.  Bel- 
combe's  case^  the  WT)mb  was  found  twelve  weeks  after  delivery  a 
large  spherical  pouch;  and  in  Dr.  Miller's  patient,^  at  the  end  of 
three  months,  it  likewise  admitted  readily  the  introduction  of  two 
fingers  into  its  cavity.  Such,  too,  must  have  been  the  state  of  the 
womb  in  the  two  cases^  (if  w^e  admit  them  as  not  too  wonderful 
for  credence)  in  wdiich  a  fall  upon  the  nates  at  once  replaced  the 
womb,  though  inverted  in  the  one  case  for  six  months,  and  in  the 
other  for  eight  years. 

Until  very  recently,  the  replacement  of  the  uterus  after  long  in- 
version, and  wdien  it  had  already  shrunk  to  small  dimensions,  was 
regarded  almost  as  an  impossibility;  and  of  the  few  instances  of  its 
alleged  accomplishment,  some,  at  least,  were  of  doubtful  authen- 
ticity. Dr.  White,  of  Buffalo,  however,  emboldened  by  his  success 
in  reducing  the  uterus  on  the  seventh  day  after  delivery,  as  I  have 
already  mentioned,  repeated  the   same   manipulations  with  an 

1  Op.  cit.,  vol.  i,  p.  251,  from  Med.  Zeitung,  1841,  No.  xxiii. 

2  American  Jotirnal  of  Med.  Science,  1835,  vol.  xvi,  81. 

3  Ibid.,  July,  1858,  p.  13.  •*  Cincinnati  Lancet,  July,  1859,  p.  393. 
6  Medical  Gazette,  1841,  vol.  vii,  p.  783. 

'  Ed.  Monthly  Journal,  Dec.  1851. 

'  Keported  by  Dailliez,  Observations,  33  and  34,  pp.  105  and  107.  The  second 
and  more  remarkable  of  the  two  cases  was  observed  by  Baudelocque  himself. 


THE    INVERTED    UTERUS.  195 

equally  good  result  in  another  instance  where  the  inversion  had 
existed  for  six  months.^  Dr.  Barriei-^  succeeded  in  its  reduction  at 
the  end  of  fifteen  months,  and  Dr.  White^  has  published  another 
case  in  which  he  replaced  the  uterus  at  the  end  of  fifteen  years, 
thougli  the  patient  died  of  peritonitis  sixteen  days  afterwards.  In 
all  of  these  instances  the  patients  were  put  under  the  influence  of 
chloroform,  but  the  eflbrts  at  replacing  the  womb  were  made  con- 
tinuously by  the  hand,  aided  by  the  pressure  of  a  large  bougie. 
For  these  somewhat  violent  proceedings,  Dr.  Tyler  Smitli  substi- 
tuted, with  great  ingenuity,  a  gentler  method,  which  in  his  hands 
proved  quite  successful,  he  having  by  its  means  replaced  the 
inverted  uterus  after  an  interval  of  nearly  twelve  years.*  He 
adopted  the  plan  of  keeping  up  constant  pressure  by  means  of  an 
air  pessary  in  the  vagina,  while  in  addition  twice  a  day,  for  ten 
minutes  at  a  time,  efl:brts  were  made  by  the  hand  to  restore  the 
organ  to  its  proper  position.  In  the  course  of  a  few  days  the  os 
uteri,  previously  very  small  and  rigid,  seemed  to  be  a  little  more 
dilated,  and  a  little  yielding.  No  very  great  change,  however, 
seemed  to  have  been  brought  about  until  the  eighth  or  ninth  day, 
when  after  a  night  of  considerable  uterine  pain  it  was  found  on 
the  ensuing  morning  that  the  inversion  had  completely  disap- 
peared. The  organ  showed  no  disposition  to  become  again  mis- 
placed, though  as  a  matter  of  precaution  an  air  pessary  was  worn 
for  some  time.  The  previously  profuse  hemorrhages  ceased,  men- 
struation became  regular,  and  the  patient  some  months  afterwards 
was  in  perfect  health. 

This  ingenious  plan  was  not  long  without  its  imitators.  By  its 
means  Mr.  P.  Teale,  Jr.,  of  Leeds,  succeeded  in  the  course  of  three 
days  in  the  replacement  of  a  uterus  which  had  been  inverted  for 
two  years  and  a  half  ;^  I  replaced  the  organ  in  four  days  after  it 
had  been  inverted  for  nearly  twelve  months;''  and  M.  Bockenthal' 
in  seven  days,  after  an  inversion  of  six  years'  duration.  M.- 
Bockenthal  discarded  all  manipulations,  and  confined  himself  to 
keeping  up  continuous  pressure  by  means  of  the  air  pessary,  a 
course  which  had  struck  me  too,  as  likely  to  answer  as  well  as  its 
combination  with  eftbrts  at  manual  replacement,  and  which  opinion 
Mr.  Teale,  in  a  letter  with  which  he  favored  me  on  the  subject, 
told  me  that  he  also  shared. 

It  is  disappointing,  however,  to  know  that  this  proceeding  can 
neither  be  counted  on  as  invariably  successful,  nor  even  be  regarded 
as  always  free  from  danger.  ^I.  Aran-  tried  and  abandoned  it, 
not  only  on  account  of  the  pessary  becoming  displaced  (an  incon- 
venience that  could  be  avoided  by  mounting  it  as  I  did  on  a 

1  Lor,,  cit.,  p.  17.  *  Archives  Gen.  de  Midecine,  May,  1852,  p.  100. 

3  Ainerica7i  Journal,  Jan.,  1859,  p.  282. 

*  This  case  was  rolatod  by  Dr.  Tyler  Smith,  at  a  meeting  of  the  Medico-Chirur- 
gical  Society,  on  April  14th,  1858,  and  is  published  in  vol.  xli  of  the  Traiisaciions, 
p.  183. 

*  Medical  Times,  August  20,  1859.  «  Ibid.,  October  29,  1859. 
'  Zeitschr.  f.  Geburtskunde,  vol.  xv,  p.  313. 

8  Op.  cit,  p.  M7.  The  success  of  M.  Noggerath,  of  New  York  (Zeitschr.  fiir 
Geburtsk.,  vol.  xx,  p.  200)  in  replacing  the  uterus  after  thirteen  years  of  inversion 


196  EXTIRPATION    OF 

stem,  and  connecting  it  with  a  firm  band  which  passed  round  the 
abdomen),  but  also  because  the  presence  of  the  instrument  in  the 
vagina  produced  abdominal  pain,  shivering,  and  febrile  symptoms. 
In  the  second  case,  too,  in  which  I  attempted  to  replace  the  uterus 
seven  and  a  half  months  after  delivery,  although  I  abstained  from 
all  manipulations  with  the  hands,  the  pressure  of  the  instrument 
continued  for  twelve  days,  while  it  failed  to  replace  the  womb, 
gave  rise  to  peritonitis,  of  which  the  patient  died  four  days  after 
the  pessary  had  been  removed.  The  instrument  had  produced 
complete  dilatation  of  the  os  uteri,  but  had  had  no  influence  on 
its  fundus,  the  uterine  tissue  at  the  point  of  inversion  being  hard 
and  puckered,  so  that  the  little  finger  could  with  difliculty  be 
pressed  into  the  cul-de-sac  formed  by  it.  The  hope,  therefore, 
which  at  first  was  entertained,  of  avoiding  by  this  means  all  re- 
course to  hazardous  operations  in  cases  of  chronic  inversion  of 
the  uterus,  does  not  seem  likely  to  be  fully  realized. 

The  observation  of  cases  in  which  now  and  then  women  had 
survived  the  tearing  away  of  the  uterus  by  some  ignorant  persons 
during  labor;  the  occasional  occurrence  of  instances  where  the 
inverted  uterus  had  sloughed  away,  and  the  patient  had  recovered 
from  the  accident,  and  the  overbold  surgery  of  the  sixteenth  and 
seventeenth  centuries,  to  which  alike  the  facts  and  fables  of 
Kousset'  largely  contributed,  had  familiarized  practitioners  with 
the  idea  of  extirpating  the  uterus  when  irreducibly  prolapsed  or 
inverted.  It  was  not,  however,  until  the  end  of  the  last  century, 
that  the  removal  of  the  inverted  uterus  began  to  be  admitted  as 
one  of  the  legitimate  operations  of  surgery,  and  that  the  questions 
of  its  indications,  and  of  the  best  mode  of  its  performance,  were 
carefully  considered. 

In  the  majority  of  instances,  the  indications  for  the  removal  of 
the  inverted  uterus  have  been  furnished  by  profuse  hemorrhage 
and  discharge,  exhausting  the  patient's  strength  and  threatening 
her  life;  though  in  a  few  instances,  as  in  that  where  Mr.  Chevalie? 
removed  the  organ,  the  operation  was  not  called  for  by  actual 
danger  to  the  patient's  life,  but  by  the  extreme  discomfort  which 
was  produced  by  the  tumor  hanging  between  the  patient's  thighs, 
and  l)eing  thus  exposed  to  all  kinds  of  external  injury.  The  uterus 
has  besides  been  removed  in  a  few  instances,  either  immediately 

by  manipulation  with  the  hand  alone,  would  seem  to  be  a  further  proof  of  what 
other  observations  render  probable,  that  the  varying  condition  of  the  uterus  itself 
has  at  least  as  much  to  do  with  the  success  or  the  failure  of  attempts  at  its  replace- 
ment as  the  peculiar  mode  of  proceeding  resorted  to. 

1  Foetus  Vivi  ex  Matre  Caesura,  &c. ,  8 vo. ,  Basileae,  1592.    Sectio  Quaj'ta,  pp.  100-108. 

2  Reported  bj'^  Dr.  Merriman,  in  his  Synopsis  of  Difficult  Partiu-itioii,  4th  ed., 
London,  1826,  8vo.,  p.  306.  I  may  observe  that  the  last  reported  case  of  extirpa- 
tion of  the  inverted  uterus  of  many  j^ears'  standing  and  externally  prolapsed,  re- 
ported by  Dr.  Geddings,  of  Charleston,  in  America,  at  p.  211  of  vol.  xxi  of  Kank- 
ing's  Retrospect,  warrants  great  doubts  as  to  its  having  been  an  inverted  uterus  at 
all.  The  mass  removed  was  solid,  and  with  no  trace  of  a  cavit}' .  I  have  not  in- 
cluded it  in  the  cases  which  I  have  referred  to.  I  have,  however,  included  Baxter's 
case,  Med.  Physical  Journal,  vol.  xxv,  p.  210,  though  the  objections  which  apply  to 
it  are  nearly-,  if  not  quite,  as  cogent. 


THE     INVERTED    UTERUS, 


197 


on  delivciy,  or  within  a  few  days  afterwards ;  but  with  the  excep- 
tion of  one  instance^  in  which  the  origan  had  ah'eady  passed  into  a 
state  of  gangrene,  the  operation  at  this  early  period  has  been  due 
either  to  ignorance,  or  at  least  to  errors  in  diagnosis,  and  has  been 
always  dangerous,  and  usually  fatal. 

If  we  confine  our  attention  for  the  present  to  cases  where  the 
inversion  of  the  uterus  succeeded  to  parturition,  we  shall  find  that 
forty-two  out  of  fifty-nine  cases  of  extirpation  of  the  womb  had  a 
favorable  result;  fifteen  issued  in  the  patient's  death :  and  in  two, 
though  the  patient  survived,  yet  it  was  found  necessary  to  abandon 
the  operation.' 

The  following  tabic  shows  the  results  obtained  by  the  dift'erent 
modes  of  performing  the  operation  : 


Uterus  removed  by  lit^ature  in     .     .     .  '  . 
"             "               knife  or  ecraseur,  . 
,,             ;(            f  knife  or  ecraseur  and  "1 
\      ligature,    .     .     .     j 

Recovered. 

Died. 

Operation 
abandoned. 

45 
5 

9 

33 

a 

6 

10 
2 

3 

2 

69             42 

15 

2 

The  number  of  instances  in  which  the  ligature  was  emploj^ed, 
is  so  much  greater  than  of  those  in  which  any  other  operative  pro- 
ceeding was  had  recourse  to,  as  to  preclude  any  fair  comparison 
of  their  results,  and  I  am  unable  to  contribute  anything  from  my 

1  Faivro,  Journal  de  Medecine,  August,  1786,  p.  201. 

2  References  to  thirty-six  of  the  above  cases  are  given  in  ~Mv.  Gregory  Forbes's 
excellent  paper  on  Inversion  of  the  Uterus  in  vol.  xxxv  of  the  Medico-Chiriirgical 
TrnnHactlons.     The  remainder  are  : 

Bernhard,  Lucina,  vol.  i,  p.  401. 

Staub,  Schweizer;  Zeitschr.  f.  Natnr  und  Heilkunde,  vol.  iii,  No.  1. 

Kuttlcr,  OrMe?'.  Jahrb.,  vol.  xi,  No.  1. 

Portal,  //  Filiaire  Sehezio,  Feb.,  1841. 

Michalow.«ky,  Journal  de  la  Soc.  de  Med.  de  Monipellicr,'M.w\,  1845. 

Hublier,  Bulletin  de  I' Academie  de  Mederine,  1848,  No.  41. 

The  above  references  to  cases,  all  of  which  were  successful,  are  given  by  Breslau, 
in  his  dissertation,  De  totius  uteri  exiirj)atione,  4to.,  Monachii,  1852. 

Besides  this,  there  are  successful,  and  not  mentioned  by  Forbes  or  Breslau : 

Harrison,  London  Med.  Gazette,  April,  1840,  p.  151. 

Thatcher,  related  by  Crosse,  o;?.  cit.,  p.  57.  The  inversion  took  place  in  this  case 
after  the  cxijulsion  of  a  mass  of  utt^ine  liydatids. 

Teale,  ^Icd.  T'nnes  and  Gazette,  Se))t.  1,  1855. 

Oldliam,  Gui/'.H  Ilosp.  Rrportti,  3d  Series,  vol.  i,  p.  171. 

Two  cases  by  Dr.  Putnam,  and  three  by  Dr.  Channing,  mentioned  by  Dr.  C.  A. 
Lee  in  Americmi  Med.  Journal,  Oct.,  IS'iO,  p.  313. 

Dr.  McClintock,  Clinical  Memoirs 07i  Diseases  of  Womcn,%\o.,  Dublin,  18''>3,p.  85. 

There  are,  besides,  seven  unsuccessful  cases  in  addition  to  those  referred  to  by 
Mr.  For])os,  namely : 

Symonds,  Medical  Gazette,  "Nov.,  1830. 

Mcerholdt,  in  Salomon's  dissertation,  De  uteri  inversione,  &c.,  Dorjmt,  1830,  re- 
ferred to  by  ]}reslau,  p.  40,  No.  49,  in  his  table. 

Coates,  Association  Medical  Joarnal,  July,  1855. 

Covelier,  Presse  Medicale,  and  Schmidt,  JakHiilcher,  July,  1852,  p.  182. 

Dr.  Putnam,  referred  to  by  Dr.  C.  Lee,  loc.  cit. 

Dr.  Channing,  ilMd. 

Aran,  op.  cit.,  p.  914. 


198 


EXTIRPATION  OF  INVERTED  UTERUS. 


own  experience  towards  a  solution  of  the  question.  It  may,  how- 
ever, be  worth  notice  that  in  one  only  of  the  five  cases  of  excision 
of  the  uterus  did  any  considerable  bleeding  occur;  in  one  of  the 
instances  which  terminated  fatally,  death  was  occasioned  by  peri- 
tonitis alone ;  in  the  other,  in  spite  of  the  employment  of  the 
ecraseur,  abundant  hemorrhage  into  the  abdominal  cavity  was  the 
occasion  of  the  peritonitis  under  which  the  patient  sank.  The 
dread  of  hemorrhage  which  so  long  deterred  practitioners  from 
excising  polypi,  has  been  learned  by  experience  to  be  in  great 
measure  an  exaggerated  fear ;  while  the  risk  of  inflammation  of 
the  womb  from  the  inclusion  of  some  of  its  fibres  within  the  liga- 
ture has  been  found  to  be  very  real.  It  is  deserving  of  considera- 
tion whether,  when  the  inversion  is  of  long  standing,  the  uterus 
small  and  firmly  contracted,  and  the  diameter  of  the  peritoneal 
pouch  consequently  scarcely  larger  than  a  crowquill,  while  the 
sensibility  of  the  serous  membrane  has  been  lessened  by  the  long- 
continued  change  in  its  relations,  the  risk  attending  the  excision 
would  not  be  smaller  than  tliat  associated  with  the  ligature  of  the 
uterus.  The  employment  of  the  ecraseur  would  probably  be  pref- 
erable to  the  application  of  the  ligature,  or  it  might  be  resorted 
to,  as  in  Dr.  McClintock's  case,  after  the  previous  employment  of 
the  ligature.  The  fact  that  the  ecraseur  is  not  an  absolute  safe- 
guard against  hemorrhage  does  not  negative  its  employment,  but 
nierely  suggests  the  necessity  for  much  care,  and  for  working  the 
instrument  extremely  slow. 

As  might  be  anticipated,  the  result  of  the  operation  is  to  a  very 
considerable  extent  modified  by  the  period  at  which  it  is  under- 
taken. If  performed  soon  after  delivery,  while  the  womb  is  still 
comparatively  large  and  vascular,  and  its  sensibilities  acute,  the 
prospects  of  success  are  smaller  than  if  the  misplacement  had  be- 
come a  chronic  evil  before  any  kind  of  interference  was  resorted  to. 

Table  shoiving  the  period  after  delivery  at  ivliich  the  inverted  uterus 
was  extirpated  in  fifty -five  cases. 


Patients 

Patients 

Total. 

Under  1  month, 

recovered. 

died. 

4 

3 

7 

Between  1  and  2  months, 

3 

3 

"         2—6         " 

3 

"3 

6 

"         6  —  12        " 

2 

4 

6 

"       12  —  18        " 

10 

2 

12 

"       18—2  years,   . 

1 

1 

"         2—3       " 

5 

5 

"         3—    4       " 

2 

2 

"         4—    5       " 

4 

4 

"         5—6       " 

2 

2 

"         6—    7       " 

2 

2 

After  12  years, . 

1 
"2 

i 

1 

1 

1 
1 
2 

"14       "... 

"15       "... 

"  many  "... 

'. 

41 

14 

55 

DIAGNOSIS    OF    CHRONIC    INVERSION.  199 

It  is  perhaps  deserving  of  mention,  tliat  in  one  of  the  cases 
where  tlie  operation  was  successfully  performed  within  a  month 
after  the  patient's  delivery,  the  uterus  was  in  a  state  of  gangrene, 
and  that  in  two  others  it  lay  beyond  the  external  parts,  a  position 
which  I  need  not  remind  you,  considerably  lessens  its  sensil)ility. 
The  remaining  case  was  one  in  which  the  operation  was  performed 
by  an  ignorant  midwife  with  a  razor,  and  is  an  illustration  of  the 
wonderful  power  of  repair,  even  of  most  fearful  injuries,  which 
nature  exerts  occasionally,  rather  than  an  example  that  can  serve 
for  our  guidance  in  practice. 

In  some  of  the  fatal  cases  put  on  record,  and  probabl}^  also  in 
others  which  have  not  been  published,  inversion  of  the  uterus  has 
been  mistaken  for  polypus,  and  the  error  has  only  been  discovered 
after  the  supervention  of  formidable  symptoms  of  peritoneal 
inflammation,  or  after  the  death  of  the  patient.  It  hence  becomes 
a  matter  of  considerable  importance  to  ascertain  the  nature  of  the 
case  before  any  operation  is  attempted,  lest  it  should  unexpectedly 
api)ear  that  the  ailment,  instead  of  being  one  the  removal  of  which 
is  attended  but  by  moderate  risk,  is  in  reality  one  whose  cure  is 
unavoidably  accompanied  by  most  imminent  hazard. 

A  want  of  caution  on  the  part  of  the  practitioner  is  obvious  in 
most  instances  of  inverted  uterus,  in  which  an  error  of  diagnosis 
has  been  committed.  But  still  the  diagnosis  has  now  and  then 
been  rendered  extremely  difficult  by  the  firm  contraction  of  the 
OS  uteri  around  the  inverted  body  of  the  womb,  which  is  thereby 
compressed  so  as  to  resemble  the  pedicle  of  a  growth  proceeding 
from  within  the  uterine  cavity,  and  thus  closely  to  simulate  a 
polypus.  The  history  of  the  patient  in  such  a  case,  even  if  accu- 
rately ascertained,  is  not  absolutely  conclusive,  inasmuch  as  uterine 
polypus  may  complicate  pregnancy,  and  may  both  give  rise  to 
hemorrhage  after  delivery,  and  also  to  a  tumor,  felt  on  vaginal 
examination.  The  comparative  sensibility  of  a  polypus  and  of 
the  inverted  womb  does  not  furnish  any  trustworthy  criterion ;  for 
the  sensibility  of  that  organ  is  in  many  instances  very  low,  and 
was  so  in  all  the  cases  that  came  under  my  observation  ;  while 
it  may  further  be  added,  that  there  is  no  such  dift'erenco  between 
the  appearance  of  the  tumors  as  can  be  relied  on  in  forming  a 
decision. 

Mr.  Arnott  suggested  to  me  some  years  ago  a  means  of  distin- 
guishing between  the  two,  which  appears  quite  worthy  of  being 
borne  in  mind.  Let  the  finger  be  introduced  into  the  rectum,  and 
carried  up  as  high  as  possible.  On  turning  it  round,  if  the  uterus 
be  inverted,  the  finger  will  have  been  carried  above  it,  and  will 
easily  ascertain  the  absence  of  the  organ  from  its  natural  situation 
in  the  i)clvis.  If,  on  the  other  hand,  the  vaginal  tumor  is  a 
polypus,  the  uterus  will  probably  be  found  enlarged,  and  at  any 
rate  occupying  its  proper  position.  The  uterine  sound  furnishes 
us  with  another  valuable  aid  in  doubtful  cases.  If  a  polypus  is 
present,  the  uterine  cavity  will  be  found  enlarged,  so  that  the 
sound  will  pass  flirthcr  than  natural,  and  a  sense  of  weight  will 


200  EXTIRPATION    OF    THE    UTERUS 

also,  most  likely,  be  experienced;  and  b}^  these  two  means  of 
examination  combined,  I  believe  that  in  all  cases  of  inverted 
uterus  after  labor,  an  erroneous  diagnosis  may  be  avoided. 

It  now  remains  for  me  to  ofter  a  few  suggestions  with  reference 
to  the  only  means  by  which  the  almost  inevitable  results  of  irre- 
ducible inversion  of  the  womb  can  with  certainty  be  obviated;  and 
these,  consist,  as  you  know,  in  the  extirpation  of  tlie  organ,  either 
by  the  knife  or  the  ligature.  It  is  almost  superfluous  to  say  that, 
inasmuch  as  there  are  some  few  instances  on  record  in  which  inver- 
sion of  the  womb  has  not  been  followed  b}^  the  serious  results  to 
which  it  usually  gives  rise,  so  nothing  but  most  obvious  danger  to 
the  patient's  life  will  justify  the  performance  of  an  operation  so 
hazardous  as  the  extirpation  of  the  womb.  But  further,  the  occur- 
rence of  severe  hemorrhage,  and  the  apprehension  of  its  increase 
at  each  return,  will  not  sufiice  to  render  an  operation  expedient 
within  a  few  months  after  deli  very,  since  the  chances  ofthe  patient's 
recovery  appear  to  increase  in  proportion  as  the  accident  is  of  long 
standing.  Since  also  .in  some  instances  in  which  the  function  of 
the  ovaries  has  been  kept  in  abeyance  by  lactation,  but  little  loss 
of  blood  has  occurred  for  several  months  after  delivery,  it  would 
seem  desirable  that  every  woman  sulfering  from  irreducible  inver- 
sion ofthe  uterus  should  be  encouraged  to  suckle  her  child,  in  order 
that  time  might  be  gained  for  the  occurrence  of  as  complete  an  in- 
volution of  tlie  uterus  as  possible  before  its  removal  is  attempted. 
"When  the  frequency  of  the  return  of  the  hemorrhage,  or  the 
abundance  of  the  losses  of  blood,  has  shown  the  necessity  of  inter- 
ference, it  yet  is  not  desirable  to  select  the  time  when  hemorrhage 
is  going  on  for  the  operation,  inasmuch  as  such  times  usually  cor- 
respond with  a  menstrual  period,  and  the  uterine  sensibility  is 
generally  greatest  at  those  seasons.  In  spite  of  the  general  pro- 
priety of  this  rule,  however,  it  may  be  borne  in  mind  that  if 
hemorrhage  at  any  such  period  should  threaten  life,  and  should 
not  be  restrained  by  styptics  or  by  the  plug,  a  ligature  may  be 
applied  as  a  temporary  expedient  with  great  probability  of  the  loss 
of  blood  being  thereby  restrained,'  even  though  the  ligature  should 
be  removed  some  hours  afterwards. 

In  the  use  of  the  ligature  something  seems  to  depend  on  the 
kind  of  material  employed.  Both  silk  and  whipcord  appear  to 
irritate  considerably;  and  Dr.  Johnson,  of  Dublin,  who  has  had 
greater  success  in  this  operation  than  an^^  one  else,  prefers  a  liga- 
ture of  well-annealed  silver  wire  and  dentist's  silk  twisted  together, 
as  being  more  readily  loosened  if  too  tight,  and  as  causing  less 
irritation  than  ligatures  of  other  kinds.  It  has  sometimes  been 
attempted  to  obviate  the  risk  of  inflammation  by  applying  the  liga- 
ture at  first  so  tightly  around  the  inverted  womb, as  at  once  and 
completely  to  strangulate  it.     This  proceeding,  however,  whilst  it 

1  This  result  occurred  in  Dr.  Johnson's  second  case,  with  the  effect  of  checking 
the  bleeding,  five  weeks  before  the  organ  was  actually  extirj'tated.  See  his  paper 
in  vol.  iii  of  Dublin  Hospital  Rejwrts.  * 


BY    THE    KNIFE    OR    LIGATURR.  201 

causes  intense  suffering,  does  not  appear  to  have  tlie  desired  effect ; 
and  a  preferable  plan  seems  to  be  that  of  applying  the  ligature  com- 
paratively loose,  and  of  tightening  it  gradually  day  by  day  as  the 
patient  is  able  to  bear  it.  The  great  prostration  and  severe  pain 
which  usually  attend  the  first  application  of  the  ligature  would 
probably  be  obviated  in  great  measure  by  the  administration  of 
chloroform;  the  subsequent  supervention  of  inflammatory  symp- 
toms seems  to  require  the  immediate  slackening  of  the  ligature, 
and  may  necessitate  its  complete  removal.  After  the  ligature  has 
about  half  effected  the  division  of  the  part,  there  appears  to  be  no 
sort  of  ol)jection  to  the  completion  of  the  operation  by  the  knife 
or  scissors;  but  the  double  operation  of  applying  a  tight  ligature, 
and  immediately  excising  the  womb,  does  not  seem  to  be  as  safe  a 
proceeding  as  either  the  ligature  or  the  knife  alone.  I  have  already 
expressed  mj^  opinion,  however,  that  the  substitution  of  the  ecraseur 
for  the  knife,  and  its  employment  after  the  previous  application  of 
the  ligature,  w^ill  be  found,  as  Dr.  McClintock's  cases  w^ould  lead 
one  to  believe,  to  be  the  safest  mode  of  proceeding. 

A  few  words  must  still  be  said  about  those  cases  in  which  the 
presence  of  a  polypus  in  the  cavity  of  the  womb  has  led  to  the  in- 
version of  the  organ  ;  an  accident  which,  though  probably  not 
rarer,  has  yet  been  less  frequently  noticed  than  the  inversion  of 
the  womb  after  labor.  Tlie  large  size  of  the  outgrowth,  the 
presence  of  more  tumors  than  one,  together  with  the  origin  of  the 
pol^'pus  from  the  fundus  of  the  w'omb,  arc  the  conditions  which 
have  been  met  with  in  the  majority  of  instances  where  this  acci- 
dent has  happened.  These,  however,  are  by  no  means  of  constant 
occurrence ;  for  a  very  small  tumor  has  sufficed  to  invert  the 
Avoml),'  while  the  insertion  of  the  pedicle  of  the  polypus  into  the 
fundus  of  the  uterus  is  common  to  the  greater  number  of  these 
growths;  and  the  large  size  of  the  tumor  or  the  presence  of  several 
tumors,  is  by  no  means  unusual,  without  any  disposition  to  inver- 
sion of  the  w^omb.  The  accident  seems  to  have  taken  place  wnth 
polypi  of  all  descriptions  ;  with  soft,  malignant,  or  pseudo-malig- 
nant tumors,  as  well  as  wnth  those  of  a  ffbrous  texture,  or  which 
might  be  supposed  to  be  actual  outgrowths  of  uterine  tissue;  and 
I  am  not  aware  that  in  any  instance  the  observation  has  been 
made  of  any  peculiar  relation  subsisting  between  the  substance 
of  the  womb  and  that  of  the  tumor.  In  most  of  the  instances,  I 
believe,  in  which  any  definite  history  has  been  given  of  the  pa- 
tient's previous  condition,  violent  ex})ulsive  pains  are  stated  to 
have  preceded  the  inversion  of  the  wondj.  I  need  scared}'  say, 
however,  that  violent  expulsive  efforts  are  too  frequent  a  concom- 
itant of  the  escape  of  a  polypus  into  the  vagina  to  have  much 
diagnostic  value;  while  in  a  remarkable  case  that  came  under  my 

'  Of  wliii'li  H  ninarkal)!!'  illustrntion  is  c;iven  hy  ^Ir.  Crosso,  op.  cit,  p.  47  and 
pinto  viii,  from  a  prc^paration  in  the  Musoiiiii  of  the  Royal  College  of  Surijeons  in 
i)ul)lin  ;  the  tumor  which  had  produced  com^ilotc  inversion  of  the  womb  very  little 
exceedin};  a  chestnut  i-n  si/.o. 


202  ASCENT  OF  THE  UTERUS: 

own  observation,  the  escape  of  the  polypus,  and  the  inversion  of 
the  womb  took  place  at  a  time  when  the  previously  severe  pain 
had  almost  completely  subsided. 

In  other  respects,  the  symptoms  attendant  upon  inversion  of  the 
uterus  complicating  polypus  present  nothing  at  all  peculiar — 
leucorrhoea,  menorrhagia,  and  exhausting  hemorrhages  occurring 
in  cases  of  ordinary  fibrous  tumor  or  polypus  as  frequently,  and 
to  as  great  extent,  while  the  womb  retains  its  proper  position,  as 
when  the  organ  is  inverted. 

In  a  practical  point  of  view,  that  which  it  behooves  us  to  bear  in 
mind  is,  first,  the  possibility  of  this  accident  occurring  in  any  case 
of  polypus  growing  from  the  cavity  of  the  womb,  and  the  especial 
reason  for  suspecting  it  when  any  consitlerable  or  long-continued 
expulsive  efforts  have  preceded  the  escape  of  the  polypus  into  the 
vagina:  second,  the  expediency,  before  tjdng  or  excising  any  poly- 
pus, which  either  is  very  large,  or  the  development  of  which  has 
been  accompanied  by  such  symptoms,  of  ascertaining  by  means  of 
the  sound  the  exact  dimensions  of  the  uterine  cavity,  that  we 
may  not  unwittingly  divide  or  tie  the  substance  of  the  womb 
instead  of  the  pedicle  of  the  tumor.  If  it  be  ascertained  that  the 
womb  is  inverted,  I  should  imagine  the  proper  course  would  be 
to  excise  the  polypus  suflBciently  low  down  to  avoid  all  risk  of 
seriously  wounding  the  uterus,  and  then  to  endeavor  to  replace 
the  organ  :  an  attempt  the  impracticability  of  which  seems  to 
have  not  infrequently  been  assumed  on  insufficient  grounds, 
and  which  was  accomplished  in  my  own  case  with  the  greatest 
facihty. 

Lastly,  it  must  be  borne  in  mind  that  the  uterus  may  be  in- 
verted by  the  tractions  made  at  a  polypus  in  the  endeavor  to  drag 
it  down  sufficiently  low  for  its  excision.  I  do  not  think,  indeed, 
that  there  is  much  risk  of  this  in  the  case  of  polypi  of  ordinary 
size  ;  but  the  cases  related  by  M.  Amussat,  and  one  which  occurred 
still  more  recently  in  the  practice  of  Mr.  Johnson,  of  NorAvich,* 
show  that  when  the  tumor  is  of  considerable  size  this  accident  is 
very  likely  to  occur. 

A  word  or  two,  before  concluding  this  Lecture,  may  be  added 
concerning  a  form  of  uterine  misplacement  of  no  practical  moment, 
except  as  sometimes  helping  to  throw  light  on  the  nature  of  a 
patient's  ailments,  otherwise  perhaps  obscure.  The  ancients  con- 
ceived, as  probably  you  know,  that  the  peculiar  sensation  of 
choking,  the  globus  hystericus,  from  which  women  often  suffer, 
was  due  to  a  positive  ascent  of  the  wornb  from  its  natural  situation 
in  the  pelvis.  In  order  to  expedite  its  return  to  its  proper  place, 
they  were  accustomed,  by  a  quaint  combination  of  reward  and 
punishment,  to  employ  aromatic  fumigations  to  the  vulva,  while 
fetid  gums  and  other  ill-savored  medicines  were  given  by  the 
mouth.  This  practice,  with  many  other  absurdities  of  bygone 
days,  is  exploded,  but  a  vestige  of  the  theory  still  remains  behind, 

1  See  Crosse,  op.  clt.,  p.  52. 


ITS     CAUSES    AND     IMPORT.  203 

for  it  is  alle2:ecl  by  some  continental  writers^  that  contractions  of 
the  uterine  ligaments,  or  as  some  say  of  the  peritoneum,  raise  the 
womb  from  its  proper  situation,  and  thus  supply  a  positive  mecliani- 
cal  cause  for  the  unpleasant  sensations  about  the  pelvis,  of  which 
hysterical  patients  frequently  complain.  For  my  own  part,  I 
neither  admit  the  explainition,  nor  do  I  believe  the  fact.  It  is  also 
said  that  the  greater  difficulty  with  which  the  os  uteri  is  reached 
in  the  aged  than  during  the  years  of  sexual  vigor,  and  the  narrow- 
ing of  the  upper  part  of  the  vagina  which  is  then  observed,  are 
due  to  an  actual  elevation  of  the  organ  in  advancing  years.  This, 
however,  again  appears  to  me  in  the  highest  degree  problematical. 
We  know  that  the  uterus  wastes  ;  that  the  projection  of  the  cervix 
into  the  vagina  also  disappears  from  the  same  cause ;  that  the 
vagina,  too,  becomes  atrophied,  and  that  if  the  uterus,  owing  to 
the  weakening  of  its  supports,  do  not  sink  down,  and  so  distend 
the  vagina,  the  calibre  of  that  canal  will  become  much  narrower 
than  it  was  before.  I  am  cpiite  at  a  loss  to  understand  what  causes 
operating  in  old  age  can  tend  really  to  raise  the  uterus  higher  than 
it  was  before ;  nor,  in  fact,  am  I  convinced  that  such  an  elevation 
of  the  organ  actually  takes  place. 

But,  though  ascent  of  the  womb  does  not  call  for  notice  as  a 
condition  of  itself  producing  any  definite  symptoms,  it  is  yet  of 
importance  to  bear  in  mind  the  difterent  circumstances  in  which 
we  are  likely  to  find  the  organ  occupying  a  higher  situation  than 
usual. 

1st.  It  is  a  physiological  attendant  upon  pregnancy,  from  about 
the  fourth  to  the  eighth  month,  is  especially  marked  in  first  preg- 
nancies, is  sometimes  so  considerable  as  to  render  it  a  matter  of 
extreme  difficulty  to  reach  the  os  uteri.  With  moderate  attention, 
however,  to  the  patient's  history,  and  consideration  of  all  the  cir- 
cumstances of  her  case,  the  peculiarities  presented  by  the  pregnant 
OS  uteri  will  seldom  fail  to  keep  the  practitioner  from  error. 

2d.  When  any  considerable  degree  of  pelvic  contraction  exists, 
the  want  of  space  often  obliges  both  the  uterus  and  bladder  to 
remain  above  the  pelvic  brim,  a  circumstance  to  which  much  of 
the  difficulty  of  the  operation  of  craniotomy  is  frequently  due. 

3d.  In  cases  of  inflammation  of  the  pelvic  cellular  tissue,  or 
of  that  between  the  folds  of  the  broad  ligament,  the  uterus  is  often 
found  very  high  up,  so  that  its  orifice  is  reached  Avith  difficulty. 
This  change  in  the  position  of  the  organ,  too,  is  not  necessarily 
due  to  the  formation  of  a  tumor  lower  down  in  the  pelvic  cavity, 
forcing  it  above  its  natural  situation,  though  it  may  of  course  be 
produced  in  that  way ;  but  it  may  depend  on  a  positive  dragging 
of  the  womb  upwards  by  the  inflamed  tissues. 

4th.  In  a  large  number  of  instances  of  ovarian  dropsy,  the  cj'st, 
as  it  rises  out  of  the  pelvis,  draws  the  uterus  with  it,  sometimes 
even  considerably  above  its  natural  position.     In  cases  where  a 

1  Busch,  Gcschlechtslcben  dcs  Weibcs,  vol.  iii,  p.  473. 


204  ASCENT    OF    THE    UTERUS. 

question  arises  as  to  whether  an  accumulation  of  fluid  in  the  ab- 
dominal cavity  is  due  to  ascites  or  to  ovarian  dropsy,  the  relations 
of  the  uterus  often  assist  us  in  arriving  at  a  correct  conclusion, 
for  the  organ  which  is  usually  drawn  upwards  in  ovarian  dropsy 
is  generally  depressed  below  its  ordinary  situation  in  cases  of 
ascites.  More  frequently  it  happens  that  doubt  is  entertained  as 
to  the  nature  of  a  non-fluctuating  tumor,  concerning  which  it  is 
uncertain  whether  it  is  uterine  or  ovarian.  Any  considerable  ele- 
vation of  the  uterus  is  much  more  frequently  due  to  degeneration 
of  the  ovary  than  to  tumor  of  the  womb. 

5th,  and  lastly.  In  a  few  instances,  flbrous  tumors  of  the  uterus 
as  they  increase  in  size  raise  the  organ  more  and  more  out  of 
reach.  Nothing,  indeed,  is  more  common  in  cases  where  the  uterus 
is  the  seat  of  several  fibrous  tumors,  some  of  which  have  attained 
to  a  considerable  size,  than  to  find  the  organ  so  much  deformed 
that  the  os  becomes  situated  high  up  behind  one  or  other  side  of 
the  ramus  of  the  pubis.  But  besides  those  cases  in  which  the 
firm  irregular  outgrowths  felt  per  vaginam  leave  no  room  for  un- 
certainty, there  are  a  few  exceptional  instances  in  which  a  single 
fibrous  tumor  in  the  uterine  wall,  without  producing  any  deformity 
of  the  organ  appreciable  per  vaginam,  raises  it  in  the  progress  of 
its  development. high  out  of  the  pelvic  cavity.  In  this  process, 
however,  the  greatly  elongated  cervix  uteri  scarcely  participates 
in  the  growth  of  the  body  of  the  organ,  but  becomes  mechanically 
stretched  till  it  attains  sometimes  the  length  of  several  inches.^  As 
a  result  of  this  the  lips  of  the  os  uteri  become  extremely  thin,  or 
disappear  almost  entirely,  leaving  the  os  a  funnel-shaped  entrance 
with  almost  membranous  margins  to  the  elongated  and  narrow 
cervical  canal.  "When  drawn  upwards  by  the  enlarged  ovary,  the 
traction  is  exercised  on  the  body,  not  on  the  neck  of  the  womb, 
and  hence  no  change  is  produced  in  the  character  of  the  lips  or 
OS  uteri. 

With  these  hints,  not  without  their  use  perhaps  in  the  diagnosis 
of  uterine  afiections,  we  may  take  leave  of  the  subject  of  malpo- 
sitions of  the  womb,  and  must  at  the  next  Lecture  commence  the 
study  of  another  and  most  important  class  of  its  diseases. 

1  As  in  the  very  remarkable  case  described  and  delineated  by  Professor  Walter, 
of  Dorpat,  in  which  the  cervix  was  two  inches  and  three  quarters  long,  and  scarcely 
any  indication  of  the  uterine  lips  was  perceptible.  See  p.  10,  of  his  Essay  Ucber 
Fibrose  Korper  der  Gebdrmutter,  4to. ,  Dorpat,  1852. 


UTERINE    TUMORS    AND    OUTGROWTHS.  205 


LECTURE    XIV. 

UTERINE  TUMOKS  AND  OUTGEOWTHS. 

Their  occurrence  connected  with  tendency  of  uterus  to  hypertrophy  generally. 
Outgrowths  of  the  mucous  membrane,  or  Mucous  Polypi  ;  their  simplest  form. 

Ii^ihro-Cellular  Polypi.    Glandular  Polypi  from  hypertrophy  of  uterine 

follicles. 
Cystic  enlargement  of  follicles  of  cervix,  or  Mucous  Cysts  of  the  Uterus. 
Symptoms  of  these  afiections:  nature  and  source  of  the  hemorrhage  they  occasion. 

Diagnosis.     Treatment. 
Fibrinous  Polypus,  its  nature;   analogy  to  other  chronic  effusions  of  blood. 

Note  on  some  other  alleged  varieties  of  polypus. 

In  the  course  of  the  foregoing  Lectures  I  have  referred  over 
and  over  again,  with  an  iteration  tliat  can  scarcely  have  failed  of 
being  wearisome,  to  the  ready  increase  of  the  womb  under  the 
influence  of  very  various  exciting  causes.  We  have  seen  that  in- 
flammation going  on  to  the  production  of  its  ordinary  conse- 
quences— suppuration,  or  the  eflrusion  of  lymph — is  of  very  rare 
occurrence.  Abscess  of  the  womb  is  one  of  those  accidents  so 
uncommon,  that  when  met  with  it  seldom  fails  to  be  recorded 
among  what  the  old  writers  used  to  term  Curiosa  Medica;  and 
the  eifusion  of  lymph  into  the  tissue  of  the  organ  has  been 
assumed  in  accordance  with  certain  physiological  or  pathological 
hypotheses  rather  than  actually  demonstrated. 

It  is  indeed  scarcely  ever,  except  after  labor  or  miscarriage, 
when  the  tissue  of  the  womb  passes  physiologically  through 
changes  such  as  those  which  inflammation  tends  to  work,  that 
the  diseased  process  manifests  itself  in  its  acute  forms,  or  with 
dangerous  severity,  while,  even  then,  the  serous  investment  of 
the  organ,  or  the  lining  membrane  of  its  veins,  is  generally  the 
part  which  shows  marks  of  the  most  serious  mischief.  Often,  too, 
the  signs  of  inflammation  appearing  at  these  times,  turn  out  to  be 
symptomatic  less  of  aft'cction  of  the  womb  itself  than  of  its  ap- 
pendages or  of  the  cellular  tissue  in  its  vicinity,  or  connecting 
together  the  different  pelvic  viscera.  At  the  same  time,  however, 
we  And  that  the  causes  which  elsewhere  might  issue  in  inflamma- 
tion produce  in  the  case  of  the  womb  its  overgrowth.  It  increases 
from  that  frequent  afflux  of  blood  towards  it  which  jiroduccs 
many  forms  of  menstrual  disorder;  it  remains  pennanently  in- 
creased from  deflcient  involution  after  labor;  it  enlarges,  if  flexed 
or  misplaced,  and  its  prolapsus  causes  it  in  many  instances  to 
attain  to  more  than  double  its  ordinary  size. 

But  not  only  is  hypertrophy  of  the  M'omb  more  frequent  than 
the  hyi»ertrophy  of  any  other  organ,  but  each  of  its  conqionent 
tissues  is  liable  to  a  similar  overgrowth — not  regular  indeed,  and 
equable,  but  in  [)arts,  here  and  there,  constituting  tumors  and  out- 
growths, which  are  met  with  in  this  oftener  than  iu  any  other 


206  UTERINE    TUMORS    AND    OUTGROWTHS. 

part,  and  of  which  frequency  the  physiological  peculiarities  of  the 
womb  furnish  the  only  explanation.  The  mucous  membrane  of 
the  uterine  cavity  undergoes,  as  we  have  already  seen,  an  occa- 
sional hypertrophy  in  some  menstrual  disorders,  but  becomes 
eventually  cast  oft"  in  accordance  with  the  laws  which  regulate  its 
development  iu  a  state  of  health  and  uuder  the  influence  of  preg- 
nancy. But  the  mucous  membrane  of  the  cervix  also  sometimes 
becomes  hypertrophied,  and  such  hypertrophies  are  not  decidu- 
ous, but  assume  the  form  either  of  a  distinct  fold  at  the  orifice  of 
the  womb,^  or  more  frequently  of  distinct  small  pendulous  out- 
growths. Now  and  then,  the  admixture  of  a  larger  quantity  of 
cellular  tissue  than  usual  gives  to  these  growths  a  more  consider- 
able size  than  they  attain  to  when  composed  exclusively  of  mucous 
membrane.  Sometimes  the  same  process  of  overgrowth  aft'ects  the 
celluUir  structure  of  the  neck  of  the  womb,  and  then  a  peculiar 
form  of  outgrowth  is  produced,  termed  the  glandular  or  ceHular 
pol^q^as  of  the  cervix  uteri.  If  one  of  these  follicles  alone  in- 
creases at  the  expense  of  the  others,  and  without  a  corresponding 
hypertrophy  of  the  cellular  structure  or  mucous  membrane,  there 
are  then  produced  those  cysts  of  the  neck  of  the  womb  whose 
nature  and  origin  were  once  so  little  understood.  Lastly,  if  the 
same  process  involves  the  uterine  substance  itself,  we  then  meet 
with  the  so-called  fibrous  tumors  of  the  womb,  which,  identical 
with  it  in  their  intimate  structure,  differ  only  in  this,  that  they  are 
not  developed  in  accordance  with  the  general  contour  of  the 
organ  in  which  they  arise;  but,  springing  from  various  centres, 
grow  with  no  symmetry  towards  its  outer  or  its  inner  surface,  and 
produce  symptoms  which  vary  according  to  their  scat  and  the 
vigor  of  their  growth. 

With  reference  to  these  and  other  varieties  of  growths  from  the 
womb,  it  is  not  altogether  without  importance  to  observe  that  the 
time  of  their  appearance  is  just  that  at  which  all  the  physiological 
changes  in  the  organ  go  on  with  the  greatest  activity,  and  that 
they  are  rarely  met  with  either  in  the  season  of  decrepitude  or  of 
early  youth.  The  same  fact,  too,  holds  good  to  a  great  extent  with 
reference  to  another  great  class  of  ailments  of  the  uterus;  those, 
namely,  of  a  malignant  character.  These,  also,  occur  chiefly  in 
the  season  of  sexual  activity,  and  seem  to  be  connected,  as  in  the 
case  of  the  female  breast,  with  the  wide  fluctuations  in  growth 
and  in  activity  which  succeed  each  other  in  those  parts  within  very 
brief  intervals. 

Having  thus  thrown  out  a  suggestion  that  may  perhaps  explain 
in  some  degree  the  singular  liability  of  the  womb  to  various  tumors 
and  outgrowths,  I  propose  to  examine  each  kind  in  succession, 
beginning  with  those  of  simplest  character,  namely  outgrowths 

1  As  well  delineated  by  Dr.  Tyler  Smith  in  pi.  ix  of  his  Essay  in  the  Med.  Chir. 
Transactions,  vol.  xxxv. 


MUCOUS    POLYPI.  207 

from  the  uterine  mucous  membrane;  the  mucous  j^ohjin  of  most 
writers  on  the  diseases  of  women. ^ 

These  generally  appear  as  small  outgrowths  from  the  folds  of  the 
so-called  arbor  vitce,  varying  from  a  third  to  half  an  inch  in  length 
by  about  three  lines  in  thickness  ;  the  pedicle  by  which  they  are 
connected  with  the  mucous  membrane  being  generally  exceedingly 
slender,  though  at  the  same  time  very  short.  It  would  seem  as  if 
they  were  originally  duplicaturcs  of  the  mucous  membrane,  of 
equal  thickness  throughout,  and  as  if  tlie  gradual  constriction  of 
their  pedicle  were  the  process  by  which  nature  gets  rid  of  them, 
just  by  the  same  means  as  those  by  which  the  loose  cartilages  in 
the  knee-joint  are  by  degrees  detached  from  their  connection  with 
the  synovial  membrane  whence  they  originally  sprang.  They  are 
usually  of  a  bright  rose  tint,  abundantly  sup[)lied  with  a  delicate 
network  of  vessels,  and  consist  exclusively  of  mucous  membrane 
with  a  very  small  admixture  of  cellular  tissue.  The  seat  of  these 
little  bodies  is  nearly  always  the  cervical  canal,  from  any  part  of 
which  they  may  arise,  though  they  are  usually  nearer  the  external 
than  the  internal  os  uteri,  and  now  and  then  I  have  found  a  single 
growth  of  this  kind  in  the  uterine  cavity,  but  quite  at  its  lower 
part.  Though  generally  pediculated,  as  just  now  described,  they 
are  now  and  then  sessile,  of  a  flatter  form,  and  adherent  along  the 
whole  of  one  of  their  surfaces  to  the  mucous  membrane.  Occa- 
sionally, too,  they  do  not  assume  the  form  of  distinct  outgrowths, 
but  a[)pear  like  hypertrophied  folds  of  the  arbor  vitse,  bearing  the 
same  relation  to  the  walls  of  the  cervix  as  the  attached  carueae 
columnfe  do  to  the  parietes  of  the  heart. 

Sometimes  these  growths  are  solitary,  but  it  is  at  least  as  fre- 
quent for  two  or  three  of  them  to  be  found  in  the  same  patient; 
they  have  a  disposition  also  to  be  reproduced ;  or  at  least  succes- 
sive growths  form,  so  that  it  is  not  unusual  for  a  patient  from 
whom  they  have  once  been  removed  to  require  a  repetition  of  the 
operation  after  the  lapse  of  a  few  months.  I  have  known  them 
coexist  with  fibrous  tumors  of  the  uterus,  but  do  not  imagine  that 
this  was  the  result  of  more  than  a  mere  coincidence,  and  have 
never  seen  reason  for  regarding  them  as  the  precursors  of  malig- 
nant disease,  though  the  late  Dr.  Montgomery,  of  Dublin,-  be- 
lieved this  to  be  not  infrequently  so  in  the  aged. 

Those  outgrowths,  which  are  simple  excrescences  from  the  mu- 
cous membrane,  never  exceed  the  very  small  dimensions  which  1 
have  just  specified.  Sometimes,  however,  a  larger  quantity  of 
cellular  tissue  enters  into  their  composition,  and  they  then  acquire 
a  much  larger  size,  and  bang  down  beyond  the  os  uteri  into  the 
vagina.  They  are  often  the  size  of  a  small  fig,  of  a  flattened  form, 
and  are  found  to  be  made  up  oi  jihro-cellular  tissue,  having  an  in- 

1  liha papillary  polypi  of  Hirsch,  whose  Essay  Ueber  die  Hisiolopic  und  Foiinen 
der  Uterns-Pijlypen,  8vo.,  Giessen,  1865,  is  a  valuable  contribution  to  this  depart- 
ment of  morbid  anatomy. 

2  In  a  very  valuable  paper  on  "Polypus  of  the  Uterus"  in  the  Dublin  Journal 
of  Medical  Science  for  August,  1846. 


208  CYSTS    OF    THE    CERVIX    UTERI. 

vestment  of  mucous  membrane,  while  they  do  not  proceed  exclu- 
sively from  the  cervix,  but  have  their  origin  also  sometimes  within 
the  cavity  of  the  womb. 

IMore  frequent  than  these  are  polypi  of  a  more  complex  structure, 
into  the  formation  of  which  there  enter  not  merely  the  mucous 
membrane  of  the  uterus  or  its  hypertrophied  iibro-cellular  tissue, 
but  also  the  large  mucous  follicles  of  the  cervix.  These  polypi 
assume  different  forms,  being  sometimes  pediculated,  and  the 
pedicle  is  occasionally  of  considerable  length;  at  other  times  they 
appear  as  continuous  outgrowths  from  the  inner  surface  of  one  or 
other  uterine  lip,  most  commonly,  I  think,  of  the  anterior.  On 
dividing  them,  their  most  striking  peculiarity  is  at  once  seen,  for 
they  are  found  to  contain  a  large  quantit}'  of  tenacious,  transparent, 
albuminous  matter,  precisely  similar  to  that  which  is  secreted  by 
the  Nabothian  glands.  Sometimes,  when  the  growth  is  still  small, 
vesicles  varying  from  the  size  of  a  pea  to  that  of  a  kidney-bean, 
filled  with  this  albuminous  matter,  compose  the  great  bulk  of  the 
tumor,  their  walls  still  partially  transparent,  but  readily  distin- 
guishable beneath  the  delicate  mucous  membrane  with  which  the 
whole  is  invested.  In  other  instances,  however,  and  generally 
whenever  the  bigness  of  the  growth  exceeds  the  size  of  the  first 
joint  of  the  thumb,  the  vesicles  are  not  so  distinct,  though  the 
structure  is  equally  characteristic.  In  the  midst  of  the  succulent 
fibro-cellular  tissue  which  enters  into  the  composition  of  tlie  tumor, 
there  are  numerous  canals,  whose  walls  are  of  a  denser  structure, 
arranged  longitudinally,  side  by  side,  some  of  them  communicat- 
ing with  each  other  towards  the  pedicle,  but  not  by  any  cross 
branches.  These  canals  are  all  directed  towards  the  surface  of  the 
tumor,  where  some  of  them  terminate  in  blind  pouches.  Others 
end  in  openings  mostly  of  an  oval  form,  and  invariably  smaller 
than  the  calibre  of  the  tube  itself.  Their  length  is  not  quite  uni- 
form, and  hence  it  results  that  the  tumor  has  a  peculiar,  uneven, 
almost  lobulated  surface,  closely  resembling  in  this  respect  the 
appearance  of  an  hypertrophied  tonsil.  They  are  filled  with  the 
same  albuminous  nuitter  as  in  the  smaller  outgrowths  is  contained 
in  the  vesicles  I  mentioned,  and  the  origin  of  both  appears  to  be 
the  same,  namely,  the  mucous  follicles  of  the  neck  of  the  womb. 
The  long  pedicle  with  which  these  growths  are  sometimes  fur- 
nished' does  not  contain  any  of  the  hypertrophied  follicles,  but  is 
composed  entirely  of  fibro-cellular  tissue.  Usually,  however, 
the  pedicle  is  very  short,  and  the  point  of  origin  of  the  gro^^i;h 
low  down  in  the  cervical  canal.  Though  freely  supplied  with 
vessels,  these  growths  do  not  in  general  present  any  considerable 
vascularity  of  the  surface,  which  may  be  stated  on  the  authority 
of  Virchow,^  to  be  composed  of  very  dense  cellular  tissue,  covered 
by  a  thick  layer  of  tessellated  epithelium, 

1  See  Boivin  et  Duges,  Maladies  de  V  Uterus^  &c.,  Atlas,  pi.  xvii,  fig.  2,  and  pi. 
xix,  flg.  2. 

2  In  the  Archiv.  fur  Pathol.  Anatomie  und  Physiologie,  vol.  vii,  1854,  p.  164,  and 
plate  ii,  figs.  5  and  6.     A  very  good  description  of  the  general  characters  of  this 


SYMPTOMS    OF    MUCOUS    POLYPI.  209 

Lastly,  in  connection  with  this  class  of  ailments,  may  be  men- 
tioned the  occasional  enlargement  of  the  follicles  of  the  cervix  uteri, 
unconnected  with  any  outgrowth  of  its  proper  tissue,  or  any  hyper- 
tropliy  of  its  mucous  membrane,  but  assuming  the  form  of  ci/sts, 
whose  development  takes  place  at  the  expense  of  the  uterine  sub- 
stance. Sometimes,  too,  though  I  believe  not  in  the  majority  of 
cases,  these  cysts  or  vesicles  are  altogether  new  formations;  and 
are  not  produced  by  the  mere  enhirgement  of  occluded  follicles. 
Such,  at  least,  is  the  conclusion  which  Hie  examination  of  their 
structure  by  the  microsco[)e  leads  us  to  adopt.  In  examining  the 
uterus  after  death,  it  is  by  no  means  unusual  to  observe  several 
vesicles  of  the  size  of  a  pea  imbedded  between  the  folds  of  the 
arbor  vit^e,  but  scarcely,  if  at  all,  projecting  beyond  the  level  of 
the  mucous  membrane.  This  size,  however,  may  be  greatly  ex- 
ceeded. In  the  uterus  of  a  woman,  aged  twenty-nine  years,  which 
presented  no  other  appearance  of  disease,  all  the  Nabothian  glands 
were  much  enlarged,  and  the  whole  cervical  canal  was  filled  with 
their  secretion;  while  at  the  upper  jDart  of  the  cervix  uteri  was 
one  of  these  cysts  as  large  as  a  kidney  bean,  distended  with  albu- 
minous matter,  and  having  by  its  increase  produced  the  absorption 
of  almost  the  whole  of  the  uterine  wall,  which  was  scarcely  a  line 
in  thickness.  The  cyst  had  produced  a  degree  of  bulging  out- 
wardly of  the  attenuated  uterine  wall,  such  as  must  have  been 
obvious  during  life,  and  b}'  which  I  believe  that,  on  one  or  two 
occasions,  I  have  recognized  this  affection,  which  might,  but  for 
other  symptoms,  be  taken  for  a  solid  tumor  of  the  neck  of  the 
womb.^ 

Though  I  have  met  with  many  more  cases  in  practice,  yet  I  have 
preserved  notes  of  only  twenty-three  instances  of  these  varieties  of 
uterine  polj'pi,  a  circumstance  readily  explicable  by  the  speedy  and 
complete  removal  of  the  ailment  by  a  very  slight  and  simple  opera- 
tion. Of  the  twenty-three  cases,  five  occurred  in  single,  eighteen 
in  married  women,  of  whom  twelve  had  given  birth  to  children  at 
the  full  period,  one  had  aborted  several  times,  and  five  had  never 
been  pregnant.  The  age  of  the  youngest  patient  was  twenty-three, 
that  of  the  oldest  fifty-seven  ;  and  the  average  age  of  all  was  forty 
years.  The  symptoms  which  induced  the  patients'  to  seek  for 
medical  aid  had  existed  for  periods  varying  from  three  months 
to  four  years;  and  were  in  every  instance  very  similar  in  kind, 
though  varying  greatly  in  degree.  Either  leucorrhoeal  discharge, 
or  hemorrhage,  or  both  existed ;  to  which  bearing-down  i)ams 
were  sometimes,  though  by  no  means  constantly,  superadded. 

Once  or  twice  I  have  accidentally  discovered  small  polypi  in 

kind  of  polypus  and  a  diagram  of  its  structure  were  given  by  Dr.  Oidliani  in  Guy's 
Hi)fi])Hal  Reports,  2d  scries,  vol.  ii.  It  has  also  been  well  described  by  Huguier  in 
the  Memoiri-s  de  la  Sndefe  de  Cfiinirgie  de  Paris,  vol.  i,  1847,  p.  35. 

'  An  extremely  elaborate  jiapcr  on  this  subject,  with  several  illustrative  drawings, 
has  been  published  by  M.  Huguier,  in  the  lirsl  volume  of  the  Memoirci  de  la  Sucieti 
de  fViirnn/ir,  pp.  241-295,  and  plates  i-iii.  The  other  portions  of  this  Essay  will 
call  for  notice  hereafter. 

14 


210  SYMPTOMS    OF    MUCOUS    POLYPI. 

cases  where  they  had  produced  no  sj^mptoms  whatever.  This, 
however,  is  unusual,  for  hemorrhage  is  very  generally  present, 
though  its  amount  seems  to  be  in  great  measure  dependent  on  the 
relation  the  polypi  bear  to  the  cervical  canal ;  being  usually  much 
more  considerable  if  the  growth  is  inclosed  within  the  lips  of  the 
OS  uteri,  than  if  it  projects  beyond  them  and  hangs  down  into  the 
vagina.  This,  indeed,  is  what  might  be  expected  beforehand,  and 
it  serves  to  explain  thejiistory  which  patients  occasionally  relate 
of  themselves,  that  the  hemorrhage  which  at  one  time  had  been 
profuse  has  at  length  greatly  diminished,  or  even  altogether  ceased. 
The  influence  of  these  small  poh'pi  in  producing  uterine  irritation 
is  sometimes  exemplified  hy  their  giving  rise  to  considerable  en- 
largement of  the  neck  of  the  womb,  and  a  degree  of  hardness  con- 
sequent on  engorgement  of  the  part  from  the  considerable  afilux 
of  blood  thither;  a  condition  that  may  lead  the  practitioner,  unless 
on  his  guard,  to  overlook  the  real  nature  of  the  ailment,  and  to 
suppose  that  he  has  to  do  with  hypcrtro^Dhy  and  induration  the 
result  of  some  bygone  inflammation  of  the  neck  of  the  womb. 
This  same  fact  also  explains  why  it  is  that  a  comparatively  large 
polypus  hanging  down  into  the  vagina  may  be  unaccompanied 
with  bleeding,  while  an  extremely  small  outgrowth  still  included 
within  the  neck  of  the  womb  may  occasion  very  formidable  hemor- 
rhage. 

These  simple  facts  point,  1  believe,  to  the  solution  of  a  much 
mooted  question  ae  to  the  source  of  the  hemorrhage  in  these  and 
other  varieties  of  uterine  polypi  and  tumors.  The  growths  are 
themselves  well  supplied  with  vessels ;  if  wounded  they  bleed ;  if 
excised,  the  hemorrhage  which  takes  place  from  their  pedicle  is 
sometimes  considerable,  has  even  been  known  to  prove  dangerous; 
but  yet  all  evidence  goes  to  prove  that  it  is  rather  from  the  womb 
itself  than  from  the  outgrowth  that  the  principal  bleeding  flows, 
and  that  the  hemorrliage  is  proportionate,  less  to  the  size  of  the 
outgrowth  than  to  the  intimacy  of  the  relation  between  it  and  the 
womb.  Of  this  I  saw  some  years  ago  a  very  remarkable  exempli- 
fication. A  woman  came  under  my  care  who  for  three  3'ears  had 
suflered  from  very  profuse  hemorrhages,  which  had  ceased  without 
known  cause  for  three  months  before  I  saw  her.  The  non-appear- 
ance of  the  menses  for  the  same  period  did  not  engage  my  attention 
as  it  ought  to  have  done ;  and  I  accordingly  excised  a  fibrous  polypus 
the  size  of  a  small  hen's  egg,  which  grew  by  a  short  pedicle  from 
the  inside  of  the  cervix  uteri.  Very  profuse  bleeding  followed  the 
operation,  but  no  other  untoward  sj- niptom ;  and  within  six  months 
more  the  patient  was  confined  at  the  full  term  of  pregnancy.  I  do 
not  relate  the  case  now  for  the  sake  of  the  moral  to  be  drawn  from 
it  with  reference  to  the  absolute  necessity  of  care  in  your  diagnosis, 
though  in  this  respect  it  comments  on  itself,  but  because  it  illus- 
trates exceedingly  well  the  source  whence  the  most  abundant 
hemorrhage  flows.  For  three  years  the  polypus  had  irritated  the 
womb,  and  blood  had  been  abundantly  poured  out.  Pregnancy 
took  place,  there  was  increased  flow  of  blood  towards  the  part ; 


THEIR     DIAGNOSIS.  211 

tlie  poly[)US  must  have  gained  rather  than  lost  in  vascularity,  but 
no  bleeding  occurred.  The  uterine  cavity  was  now  lined  with 
decidiia,  and  its  cervical  canal  was  occupied  by  the  mucous  plug 
poured  out  from  the  J^abothian  glands,  and  thus  sheltered  from 
irritation,  the  hemorrhage  from  its  surface  ceased,  and  leucorrhoea 
alone  continued  the  evidence  of  the  presence  of  the  tumor. 

The  structure  of  the  })olypus  has,  however,  something  to  do  with 
the  nature  of  the  symptoms,  with  the  gccurrence,  and  still  more 
with  the  amount  of  the  hemorrhage.  Those  polypi  which  present 
the  compound  structure  due  to  enlargement  of  the  Xabothian 
glands,  are  always  attended  by  profuse  leucorrhoea,  a  circum- 
stance easily  ex}>licable  if  we  bear  in  mind  that  the  formation  of 
the  outgrowtli  is  associated  with  a  state  of  hypertrophy  and  over- 
activity of  the  whole  secreting  apparatus  of  the  neck  of  the  womb. 
Their  vascularity  being  less  than  that  of  the  small  mucous  polypi, 
they  are  also  more  frequently  unaccompanied  with  bleeding,  while, 
as  might  be  expected,  the  hemorrhage  is  usually  absent  when  they 
assume  the  form  of  outgrowths  from  the  inner  surface  of  one  or 
other  uterine  lip,  since  in  that  case  the  cervical  canal  escapes 
almost  entirely  from  direct  irritation. 

I  do  not  know  whether  these  growths  have  any  special  influence 
unfavorable  to  conception,  though  there  is  no  cloubt  but  that  the 
very  nature  of  the  sjanptoms  to  which  they  give  rise  is  of  a  kind 
to  lessen  the  probabilities  of  a  woman  becoming  pregnant.  I 
once  excised  a  polypus,  composed  of  enlarged  ISTabothian  glands, 
of  the  size  of  a  sugared  almond,  from  the  anterior  lip  of  the  uterus 
of  a  young  woman  who  had  lived  for  more  than  eighteen  months 
in  sterile  marriage,  but  who  became  pregnant  within  a  month 
afterwards,  and  was  delivered  of  a  living  child  at  the  full  period, 
liere,  however,  the  relations  of  the  tumor  were  such  as  mechani- 
cally to  narrow,  and  almost  to  occlude  the  uterine  orifice. 

The  enlargement  of  one  or  more  of  the  follicles  of  the  cervix,  so 
as  to  form  distinct  cysts  in  the  uterine  substance,  is  of  rare  occur- 
rence. In  the  few  instances  of  it  which  have  come  under  my 
observation,  a  profuse  albuminous  discharge,  unchecked  by  treat- 
ment, or  even  by  the  free  application  of  the  nitrate  of  silver  within 
the  cervical  canal,  has  been  invariably  present.  On  one  or  two 
occasions  I  have  felt  at  the  upper  part  of  the  cervix  a  small  nodule 
which  might  readily  be  takCn  for  a  small  fibrous  tumor,  but  which 
may  be  known  by  its  yielding  slightly  on  firm  pressure,  and  by  its 
size  not  being  invariabl}^  the  same  at  different  times.  I  liave 
not  found  these  cysts  associated  with  menorrhagia,  though  that 
symptom  was  present  in  some  of  the  cases  related  in  M.  Iluguier's 
essay  on  this  afiection. 

I  do  not  know  of  any  special  difficulty  attending  the  diagnosis 
of  these  outgrowths,  nor  of  any  particular  rules  which  can  be  laid 
down  for  the  avoidance  of  error.  Tiie  very  small  jtolypi  are  some- 
times scared}'  perceptible  by  the  finger,  and  I  have  already  referred 
to  the  enlargement  of  the  cervix  wliich  they  occasionally  jn'oduce, 
and  which  is  lilsfcly  to  mislead  the  unwary.     The  only  rule  that 


212  TREATMENT    OF    SMALL    POLYPI. 

can  be  given  for  practical  guidance,  is,  however,  this :  that  in  no 
case  of  long-continued  menorrhagia  should  we  be  content  with 
mere  digital  examination,  but  should  invariably  employ  the  specu- 
lum ;  and  further,  if  no  satisfactory  conclusion  be  thereby  arrived 
at,  we  should  dilate  the  os  uteri  with  sponge  tents,  in  order  that 
the  cervical  canal  may  be  brought  within  reach  both  of  examina- 
tion with  the  finger  and  with  the  speculum.  If  these  precautions 
be  neglected,  the  patient  whom  we  have  failed  to  relieve  may 
place  herself  under  some  more  careful  practitioner,  who  will  at 
once  detect  the  cause  of  her  symptoms,  and  cure  her  by  an  ex- 
tremely simple  operation. 

For  the  most  part,  nothing  is  more  easy  than  the  removal  of 
these  small  outgroivths.  The  smallest  may  be  removed  by  laying 
hold  of  them  with  a  pair  of  long  forceps,  and  twisting  them  off, 
while  those  which  are  somewhat  larger,  after  being  twisted  to 
check  the  risk  of  bleeding,  may  be  cut  otf  with  a  pair  of  scissors. 
The  bivalve  speculum  should  always  be  employed  in  doing  this, 
and  both  forceps  and  scissors  are  made  for  the  purpose,  so  con- 
structed as  to  be  readily  worked  within  the  speculum.  To  attempt 
their  removal  by  means  of  forceps  or  scissors  simply  guided  by  the 
hand,  is  at  best  but  a  bungling  mode  of  proceeding,  while  besides, 
the  risk  of  hemorrhage  is  much  greater  than  it  would  be  if,  after 
the  removal  of  the  polypus,  the  part  whence  it  sprang  were  touched 
with  the  solid  nitrate  of  silver,  a  precaution  which  I  now  never 
omit.  Sir  C.  Locock^  has  described  a  sort  of  long  gouge,  which 
he  has  contrived,  with  much  ingenuity,  for  tlic  removal  of  small 
polypi  of  the  cervix  uteri ;  but  these  bodies,  often  so  small  as  to  be 
scarcely  distinguishable  by  the  finger,  are  also  far  too  movable  to 
be  readily  detached  by  any  instrument  introduced,  as  this  must 
be,  pretty  much  at  a  venture,  and  I  have  found  it,  on  trial,  practi- 
cally useless.  In  the  case  of  the  sessile  outgrowths,  which  I  spoke 
of  as  occasionally  resembling,  in  their  rehitions  to  the  uterine 
walls,  those  of  the  carnese  columnse  to  the  heart,  I  have  a])plied 
the  acid  nitrate  of  mercury  by  means  of  the  speculum,  and  by  this 
proceeding  destroyed  the  outgrowths,  and  arrested  the  bleeding. 

In  the  case  of  the  larger  growths,  made  up  either  of  fibro- 
cellular  tissue,  or  of  hypertrophied  uterine  follicles,  I  also  employ 
the  speculum  if  practicable.  If  the  outgrowth  be  too  large  to 
come  readily  within  the  blades  of  the  speculum,  while  its  struc- 
ture is  too  frail  or  its  pedicle  too  thin  to  allow  of  its  being  seized 
and  drawn  down  by  means  of  the  Museux  hooks,  I  employ  a  pair 
of  forceps  similar  to  those  used  by  surgeons  for  operations  on  the 
tongue,  with  rackwork  at  the  handles  to  insure  the  firm  closure 
of  the  instrument.  In  all  operations  of  this  kind  it  is  a  great 
convenience  to  have  the  forceps  or  hooks  made  with  a  lock  like 
that  of  the  midwifery  forceps,  by  which  means  each  blade  may 
be  introduced  separately,  may  be  carried  higher  up  along  the 
pedicle  of  the  growth,  and  made  to  seize  it  more  firmly  than  can 

1  Medico- Chimrg leal  Transactions,  vol.  xxxi,  p.  171. 


REMOVAL  OF  SMALL  POLYPI.  213 

be  done  if  the  blades  are  united,  and  liave  to  be  separated  after 
their  introduction  into  the  vagina.  ■  The  polypus  being  laid  liold 
of  by  this  instrument,  a  pair  of  curved,  blunt-pointed  scissors 
may  easily  be  carried  up  to  divide  the  pedicle,  while  any  hemor- 
rhage that  may  follow  will  usually  be  checked  with  ease  by  the 
application  of  nitrate  of  silver  through  the  speculum,  and  by  the 
subsequent  introduction  of  a  piece  of  cotton-w^ool  soaked  in  the 
tincture  of  matico,  and  which  may  be  easily  withdrawn  after  a 
few  hours  by  a  thread  previously  fastened  to  it. 

The  question  of  the  comparative  merits  of  the  ligature  and  of 
excision  can  scarcely  be  raised  with  reference  to  these  small  polypi, 
since  the  latter  proceeding  is  so  simple  and  easy,  and  with  due  care 
is  not  attended  by  any  serious  risk  of  hemorrhage.  The  forcible 
avulsion  of  polypi  is  a  rough  and  hazardous  proceeding,  a  relic  of 
barbarous  surgery;  while  their  strangulation  by  means  of  pecu- 
liar constructed  forceps'  appears  to  me  to  be  possessed  of  no 
advantage  over  the  use  of  the  ligature. 

Slight  as  in  most  cases  the  operation  for  the  removal  of  these 
outgrowths  is,  it  is  yet  a  matter  of  prudence  to  keep  our  patient 
in  bed  for  one  or  two  days  after  its  performance.  On  the  only 
occasion  in  which  I  neglected  this  precaution,  and  allowed  a 
woman  from  whom  I  had  removed  a  small  vascular  poly[)US  iu 
the  out-patient  room  to  return  home,  an  attack  of  peritonitis  came 
on  which  necessitated  her  reception  into  the  hospital,  where, 
however,  the  disease  speedily  yielded  to  appropriate  remedies. 

Since  I  became  acquainted  with  the  essay  of  M.  Huguier,  I 
have  not  met  with  any  of  those  enormous  cystic  enlargements  of 
the  uterine  follicles  whose  nature  was  described  a  short  time  since. 
I  applied,  in  the  few  instances  which  had  come  under  my  notice, 
the  solid  nitrate  of  silver  abundantly  within  the  cervical  canal, 
but  with  scarcely  any  benefit.  M.  Huguier,  however,  has  adopted, 
and  with  marked  success,  the  simple  plan  of  scarifying  the  interior 
of  the  neck  of  the  womb  previously  to  applying  the  caustic,  by 
which  means  the  cysts  are  emptied  of  their  albuminous  contents, 
and  the  caustic  comes  to  act  immediately  upon  their  secreting 
membrane. 

Allied  to  these  outgrowths  in  many  of  the  symptoms  to  which 
they  give  rise,  though  differing  in  their  essential  characters,  are 
those  accumulations  of  blood  within  the  uterine  cavity  where  it 
undergoes  certain  changes  and  a  kind  of  imperfect  organization, 
which  have  received  tlie  name  of  fbrinoiis  poh/pi.  The  late  Pro- 
fessor Kiwisch,^  who  was,  to  the  best  of  my  knowledge,  the  first 

1  A  procooding  first  suggested  by  Sir  Cljfirles  Bell,  in  his  Pri»r!ptrs  nf  Opcrnfive 
Siirf/r7-7/,  and  renewed  with  some  nindificutions  recently  by  M.  Geii>^oul,  fif  Lyons, 
in  a  pamphlet  entitled  Nouveau  procedi  pour  operer  les  Polypes  de  Matricc,  Lyons, 
8vo.,  1851. 

2  In  the  first  edition  of  his  Klinische  Vorti-a/je,  &e.,  published  in  1849,  vol.  i,  p. 
420,  ^  222.  He  made  no  addition  to  the  account  there  given  in  the  sub.<equent 
editions  of  his  book.  Four  years  before  the  appearance  of  his  observations  a  very 
characteristic  case  of  this  occurrence  was  publi.shed  by  M.  Lebert,  under  the  name 
of  Tiimeur  Fibrineuse  de  V  Uterus,  at  p.  90,  of  vol.  ii,  of  his  Physiologie  Pathologique. 


214  SYMPTOMS    AND    TREATMENT 

person  to  give  a  complete  description  of  this  affection,  admits  the 
comparative  unsuitability  of  the  epithet,  whicli  may,  however,  be 
conveniently  retained  for  the  present.  In  certain  conditions,  inde- 
pendent, as  he  believes,  of  impregnation,  consequent,  as-others 
think,  upon  previous  abortion,  the  walls  of  the  uterus  may  be  so 
soft  and  yielding  as  to  allow  of  the  gradual  accumulation  of  effused 
blood  in  the  cavity  of  the  organ.  In  the  course  of  time  the  clot 
may  not  only  pass  through  changes  that  remove  the  coloring 
matter  from  its  exterior, — which  assumes  a  dirty  white  or  grayish 
aspect,  while  portions  of  a  dark  red  hue  are  still  to  be  found  with- 
in, but  may  also  be  the  seat  of  the  same  kind  of  imperfect  organ- 
ization as  has  been  observed  in  the  case  of  hemorrhages  into  the 
arachnoid,  or  of  blood  effused  in  other  situations.'  Like  cardiac 
polypi,  so  these  become  firmly  adherent  to  the  walls  of  the  cavity 
within  which  they  form;  and  the  late  Franz  Kilian,  of  Mayence, 
found  one  whose  constituent  fibrine  was  in  various  stages  of  fibril- 
lization,  while  its  surface  had  received  a  partial  investment  of 
tessellated  epithelium,  which  he  l)clieved  to  be  due  to  the  advanced 
organization  of  the  outer  layer  of  fibrine.'^ 

The  very  nature  of  the  organ  within  which  these  collections 
form  is  unfavorable  to  that  more  complete  organization  taking 
place  in  them  which  may  occur  in  similar  effusions  in  other  parts. 
After  the  lapse  of  a  few  months  at  the  latest,  the  uterus  becomes 
irritated  by  the  presence  of  the  clot,  hemorrhage  takes  place,  the 
organ  contracts,  and  the  mass  is  at  length  expelled  with  symptoms 
almost  identical  with  those  of  an  abortion. 

The  question,  as  I  just  now  mentioned,  has  been  raised,  as  to 
whether  this  fibrinous  poly[)ns  forms  independent  of  the  previous 
enlargement  of  the  uterus  b}'  abortion  or  delivery  at  the  full  period. 
Kiwisch  believed  that  it  does  ;  and  alleged  as  characteristic  of  it 
that  the  chief  accumulation  of  blood  takes  place  not  within  the 
body  of  the  womb,  but  in  the  dilated  cervical  canal.  This  state- 
ment, however,  is  controverted  by  his  worthy  successor,  Professor 
Scanzoni  f  and  the  fact  that  the  patients  in  whom  the  accident 
occurred  were  in  every  instance  married  women,  and  that  in  all 
the  menses  had  been  suppressed  for  a  period  of  from  six  weeks  to 
three  months  previous  to  the  outburst  of  the  hemorrhage,  favors 
the  suspicion  that  conception  had  taken  place,  and  that  the  bleed- 
ing was  at  first  but  the  evidence  of  abortion.  In  this  view,  too, 
Virchow^  coincides,  and  states  that  on  a  post-mortem  examination 
he  has  invariably  found  the  base  of  the  swelling  formed  either  by 
actual  remains  of  the  foetal  placenta,  or  by  the  adhesion  of  coagula 

In  this  case  the  expulsion  of  the  mass  took  place  six  weeks  after  a  miscarriage  ;  and 
for  some  time  previous  both  the  pain  and  the  hemorrhage  which  had  accompanied 
the  miscarriage  had  altogether  ceased. 

1  On  which  subject  see  Paget's  Lechires  on  Surqical  Paihology,  vol.  i,  pp.  173-175. 

2  Henle  and  Pfeuffer's  Zeitschrift  vol.  vii,  1849,  p.  149. 

3  Verhnndliinfjeii  der  Phys.  Med.  Gesellsc.haft  in  W'drzburg,  vol.  ii,  p.  30;  and  in 
his  Lchrbuch  der  Krankheiten  der  Weiblichen  Sexualorgane,  8vo.,  3d  ed.,  Wien, 
1863,  p.  2f)5. 

*  Die  Krankhaften  Geschwiilste,  8vo.,  Berlin,  1863,  vol.  i,  p.  149. 


OF    FIBRINOUS    POLYPUS.  215 

from  the  torn  vessels  to  the  uneven  surface  of  the  maternal  placenta, 
so  that  the  question  of  the  origin  of  these  polypi  may  be  considered 
as  decided. 

The  external  os  uteri,  indeed,  closes  so  speedily  after  the  occur- 
rence of  abortion  in  the  early  months  of  pregnancy,  that  tliere  is 
no  difficulty  in  understanding  how  blood  may  slowly  collect  within 
the  cavity  of  the  organ,  and,  coagulating,  remain  there  till  by  its 
bulk  it  excites  the  contraction  of  the  womb.  The  presence  even 
of  a  very  minute  portion  of  the  ovum  greatly  favors  this  occur- 
rence, and  I  have  known  pain  and  hemorrhage  continue  for  six 
weeks  in  one  instance,  for  four  months  in  another,  after  the  sup- 
posed completion  of  an  abortion,  till  at  length  a  portion  of  decidua, 
or,  at  least,  of  a  substance  resembling  it,  was  expelled;  with  the 
discharge  of  which  the  hemorrhage  and  all  the  symptoms  disap- 
peared. 

Be  the  conditions  under  which  the  hemorrhage  occurs  what  they 
may,  the  object  of  all  treatment  would  be  the  same, — namely,  to 
empty  the  uterus  by  exciting  its  action,  and  afterwards  to  maintain 
the  contracted  state  of  the  organ.  For  this  purpose  the  removal 
of  any  coagulum  that  is  within  reach  of  the  fingers,  the  adminis- 
tration of  the  ergot  of  rye,  the  local  application  of  cold,  and  the 
injection  of  the  uterine  cavity,  are  the  means  to  Avhich  we  should 
obviously  have  recourse.  Kiwisch  was  accustomed  always  to  em- 
ploy cold  water ;  but  in  cases  of  this  description  I  have  been  ac- 
customed to  use  it  tepid,  and  have  found  it  excite  sufficiently 
enoi-getic  uterine  contractions,  without  producing  that  great  shock 
which  I  have  sometimes  seen  follow  the  injection  of  perfectly  cold 
water  into  the  cavity  of  the  unimpregnated  womb.^ 

« 

1  There  is  a  peculiar  form  of  uterine  polypus,  of  which  Dr.  R.  Lee  gives  a  de- 
lineation  in  plate  ix,  fig.  i,  of  his  beautiful,  though  unfortunately  incomplete, 
Practical  Observations  on  Diseases  of  the  Uterus,  folio,  1849,  part  ii.  He  terms  it  a 
fihro-cystic  tumor  ;  hut  his  account  of  its  structure  is  too  meagre  to  enable  one  to 
determine  its  real  nature.  Dr.  Oldham,  in  his  paper  already  referred  to,  gives  a 
sketch  of  a  similar  growth,  and  suggests  its  probable  source  in  some  peculiar  alter- 
ation or  hypertrophy  of  the  uterine  glands,  a  view  which  quite  accords  with  that 
of  Ilirsch,  who  describes  several  specimens  of  this  kind  of  outgrowth,  for  which  he 
suggests  {loc.  cit.,  p.  61)  the  name  of  the  Dccidual-polypus  of  the  body  of  the  uterus. 


216  FIBROUS    TUMORS    OF    UTERUS. 

LECTURE   XV. 

UTEEINE   TUMOES  AND  OUTGEOWTHS. 

Fibrous  Tumors; — their  general  characters,  varying  seat,  and  identity  of  micro- 
scopic structure.  Influence  of  these  growths  upon  the  uterus,  and  causes  which 
modify  it.  Their  number  and  size.  Changes  which  they  undergo,  and  nature's 
efforts  to  get  rid  of  them; — their  disintegration,  their  calcareous  transforma- 
tion. 

Frequency  of  these  growths  ; — influence  of  age  on  their  production. 

Symptoms:  disorders  of  menstruation,  hemorrhage,  pain,  sterility,  and  miscar- 
riage ;  their  comparative  frequency.     Mode  of  access  of  the  symptoms. 

General  sketch  of  symptoms  of  fibrous  tumors. 

We  are  now  about  to  enter  on  an  examination  of  one  of  the 
most  important  ailments  of  the  uterus;  one  which  is  frequent  in 
its  occurrence,  serious  in  its  results,  and  but  little  amenable  to 
treatment.  It  is,  moreover,  characterized  by  much  uncertainty 
in  its  rate  of  progress,  which,  sometimes  rapid,  is  at  other  times 
very  slow,  while  still  more  rarely,  the  disease  is  almost  or  alto- 
gether cured  by  nature,  who  either  eliminates  the  morbid  structure 
from  the  organ  whence  it  sprang,  or  effects  changes  in  it  such  as 
completely  stop  its  growth,  and  render  it  quite  harmless. 

The  fibrous  tumor  of  the  uterus  (for  this  name  seems  to  me  the 
most  appropriate  among  the  many  designations  which  it  has  re- 
ceived) is  a  growth  more  or  less  intimately  connected  with  the 
uterine  walls,  with  which  its  structure  is  almost  identical.  It  is 
seldom  solitary,  but  several  tumors  are  usually  found  to  be  present 
at  the  same  time,  though  one  or  two  generally  outstrip  the  others 
in  the  rapidity  of  their  development,  the  rate  of  which,  as  well  as 
the  nature  of  the  symptoms,  arc  greatly  influenced  by  the  situation 
that  they  occupy. 

Whatever  is  the  situation  or  size  of  one  of  these  tumors,  it  is 
characterized  by  a  spherical  form  and  a  firm  texture,  though  its 
surface  is  sometimes  nodulated,  as  if  from  the  aggregation  together 
of  several  tumors,  and  the  firm  texture  is  occasionally  interrupted 
by  irregular  spaces  or  cavities  containing  fluid,  while  many  minor 
difterences  exist  in  the  degree  of  firmness,  elasticity,  or  succulence 
of  difterent  specimens.  On  a  section  being  made  of  any  of  these 
tumors,  they  present  great  similarity  to  each  other,  being  composed 
of  a  dense  grayish  structure,  intersected  by  numerous  dead- white 
bands  and  lines  which  are  almost  invariably  arranged  according  to 
a  definite  type  or  plan.  In  some  instances  these  fibres  have  a  con- 
centric arrangement,  while  in  others  they  have  a  wavy  distribution, 
or  are  disposed  around  several  different  centres.  Tumors  of  the 
first  kind  are  usually  remarkable  for  their  hardness  and  their  small 
degree  of  vascularity  ;  they  are  also  contained  within  a  remarkably 
distinct  fibro-cellular  investment,  are  imbedded  in  the  uterine  sub- 
stance, and  seldom  attain  a  size  exceeding  that  of  a  shelled  walnut. 


STKUCTURE    OF    FIBROUS    TUMORS.  217 

The  other  varieties  are  more  vascular,  less  firm,  have  a  less  complete 
capsule,  may  occupy  all  parts  of  the  exterior  or  interior  of  the 
womb,  and  may  grow  to  a  very  large  size,  so  as  to  weigh  twenty, 
forty,  or.  even  seventy  pounds.  Moreover,  it  happens  sometimes 
that  in  the  course  of  their  development  two  or  more  tumors 
coalesce,  at  least  apparently,  so  as  to  form  a  large  growth,  though 
on  a  section  it  will  be  seen  that  the  different  growths  remain  dis- 
tinct from  each  other,  separated  by  fi])ro-cellular  septa,  the  remains 
of  the  more  complete  investment  by  which,  when  smaller,  each  was 
surrounded.  Lastly,  they  sometimes  assume  the  form  of  di.stinct 
outgrowths  from  the  uterine  substance  ;  the  fibres  of  the  womb  not 
merely  passing  over  the  tumor  at  some  parts,  or  even  over  the 
whole  of  its  surface,  but  actually  growing  into  and  being  continuous 
with  it.  This  last  form  is,  I  believe,  observed  only  in  the  case  of 
some  fibrous  tumors  growing  into  the  cavity  of  the  womb,  and 
constituting  polypi. 

None  of  these  differences,  however,  are  accompanied  by  im- 
portant modifications  in  the  essential  structure  of  these  growths. 
They  are  all  made  up  of  fibres  resembling  those  of  very  dense 
cellular  tissue,  or  of  tendinous  substance,  or  of  elastic  tissue,  pre- 
senting various  degrees  of  completeness  of  development,  and  inter- 
mingled with  cytoblasts  and  a  granular  substance,  the  abundance  of 
which  is  usually  in  inverse  proportion  to  the  perfection  of  the  fibrous 
element  of  the  growth.  In  almost  every  instance  there  are  present 
also  some  of  the  broad  unstriped  muscular  fibres  of  the  uterine 
tissue,  and  these  sometimes  enter  very  largely  into  the  composi- 
tion of  the  tumors;  while,  where  this  is  not  the  case,  the  uterine 
tissue  nevertheless  is  intermingled  with  the  pedicle  of  those  growths 
which  project  into  the  cavity  of  the  womb,  and  furnishes  them 
with  a  partial  investment,  often,  indeed,  with  a  complete  cover- 
ing.' When  to  this  we  add,  that  though  the  degree  of  vascularity 
of  these  tumors  varies  widely  in  different  instaiices,  there  is  noth- 
ing at  all  peculiar  in  the  arrangement  of  their  vessels,  and  further, 
that,  like  the  tissue  from  whence  they  spring,  they  admit  of  being 
resolved  into  gelatine  by  boiling,  we  have  mentioned  everything 
of  moment  concerning  their  composition  and  their  structure. 

There  are  several  diffbrent  situations  from  any  or  all  of  which 
these  growths  may  proceed,  and  it  is  not  very  unusual  to  meet 
with  ilUistrations  of  all  in  the  same  uterus.  Sometimes  they  are 
developed  immediately  beneath  the  peritoneum  which  covers  the 
uterus,  or  the  first  half-inch  or  inch  of  the  ovarian  ligament  or  of 
the  Fallopian  tubes.  Such  periectly  superficial  growths  are  goner- 
ally  limited  to  the  fundus  or  upper  part  of  the  body  of  the  uterus, 
are  more  frequent  on  its  posterior  than  on  its  anterior  surface,  and 
for  the  most  part  remain  of  a  very  small  size,  scarcely  exceeding 

1  Tho  first  oaroful  microscopic  oxamination  of  these  growths  was  ninflo  hy 
Valentin.  Sue  his  lieprrtoriinn,  1848,  p.  10.  In  "NVaUer's /)(.s,sr/7ai'/o>i,  already  re- 
ferred to,aretlie  results  of  thi^  microscopic  cxaniinntiun  of  tive  different  specimens, 
by  Professer  Uidder,  ?  20,  pp.  37-41 ;  and  lastly,  the  results  of  some  other  exami- 
nations are  given  by  Paget,  op.  cit.,  vol.  ii,  pp.  135,  13G. 


218  FIBROUS    TUMORS: 

the  bigness  of  a  large  pea  or  of  a  kidney  bean,  and  seldom  pro- 
ject so  far  as  to  form  more  than  the  half  of  a  much-ilattened  sphere. 
In  other  instances,  they  proceed  from  the  thickness  of  the  uterine 
wall,  and  may  then  either  grow  outwards  towards  the  peritoneum, 
or  inwards  towards  the  cavity  of  the  womb,  though  the  former  is 
by  far  the  more  frequent  occurrence,  and  is  so  doubtless  for  the 
obvioug  reason  that  in  that  direction  the  tumor  encounters  the 
least  resistance  to  its  growth.  Such  tumors  sometimes  attain  the 
size  of  a  goose's  egg,  of  a  large  pear,  or  even  a  greater  bulk,  and 
are  connected  with  the  uterus  by  a  thick  pedicle  into  which 
uterine  fibres  enter,  though,  unlike  the  tumors  that  grow  towards 
the  cavity  of  the  womb,  they  do  not  receive  an  investment  from 
its  substance.  The  tumors  that  thus  grow  outwardly  from  the 
uterine  walls  are  often  present  inconsiderable  number,  as  maybe 
seen,  for  instance,  in  a  preparation  in  the  Museum  of  St.  I>artho- 
lomew's  Hospital,  where  twelve  of  these  growths  may  be  counted 
projecting  from  the  surface  of  the  womb,  though  its  interior  is 
quite  free  from  disease.  When  they  grow  internally,  they  are 
sometimes  positive  outgrowtlis  of  the  uterine  tissue,  while  even 
when  this  is  not  tlie  case,  their  relations  to  the  womb  are  gener- 
ally very  intimate.'  They  receive  an  investment  of  uterine  tissue, 
and  are  often  much  more  abundantly  supplied  with  blood  than 
any  other  varieties  of  these  growths  ;  points,  all  of  which  are  of 
very  great  practical  moment,  modifying  the  patient's  symptoms, 
and  influencing  also  our  conduct.  Whatever  be  their  point  of 
origin,  those  growths  usually  tend,  as  they  increase  in  size,  to  be- 
come distinctly  pediculated.  To  this,  however,  there  are  occa- 
sional exceptions.  The  firm,  very  slightly  vascular  tumor,  with 
concentric  arrangement  of  its  fibres,  remains  imbedded  in  the 
uterine  substance  and  covered  by  its  investment  of  cellular  mem- 
brane, witliout  any  disposition  to  project  into  the  interior,  or  to 
protrude  at  the  exterior  of  the  organ.  In  some  cases,  too,  the 
more  vascular  variety  of  fibrous  tumor,  with  a  very  elastic  and 
very  succulent  tissue,  becomes  developed  in  the  thickness  of  one 
or  other  =uterine  wall,  attaining  the  size  of  the  fcetal  head,  or  even 
a  greater  bulk,  and  producing  very  great  enlargement  of  the  uterus, 
but  retaining  its  spherical  form,  and  continuing  imbedded  in  the 
substance  of  the  organ  rather  than  projecting  from  it  in  either 
direction.^ 

The  influence  which  these  growths  exert  upon  the  uterus  varies 
to  a  very  remarkable  extent,  but  is  in  proportion  to  the  intimacy 
of  the  relation  between  the  tumor  and  the  womb,  rather  than  to 
the  mere  size  to  which  the  tumor  itself  attains.  When  situated 
external  to  the  womb,  and  growing  into  the  peritoneal  cavity,  the 

1  The  Museum  of  St.  Bartholomew's  Hospital  contains  two  specimens  illustrat- 
ing exceedingly  well  the  difference  between  the  outgrowth  and  the  tumor,  for 
which  purpose  they  are  diagrammatized,  by  Mr.  Paget,  op.  cii.,  vol.  ii,  p.  131,  figs. 
11  and  12. 

2  A  condition  admirably  represented  in  Wenzel,  Krankheiten  des  Uterus,  folio, 
Mainz,  1816,  plates  vii  and  viii,  x  and  xi. 


THEIR    INFLUENCE    ON    THE    UTERUS.  219 

tumor  often  acquires  an  enormous  size,  and  tlie  womb  is,  as  might 
be  expected,  much  elongated,  and  strangely  deformed;  but  never- 
theless is  not  in  general  much  increased  in  bulk.  On  the  other 
hand,  the  development  of  a  siugle  tumor  within  the  substance  of 
the  womb  brings  about  an  increase  of  its  size,  a  thickening  of  its 
walls,  and  a  development  of  its  tissue  very  similar  to  those  which 
take  place  during  pregnancy.  Of  this  fact  a  preparation  in  the 
Museum  of  St.  Bartholomew's  Hospital  affords  a  very  remarkable 
illustration.  Imbedded  in  the  anterior  wall  of  the  uterus  is  a 
fibrous  tumor,  no  larger  than  an  unshoUcd  almond,  and  of  such 
slight  vascularity  that  the  injection  which  has  deeply  colored  the 
parietes  of  the  womb  has  not  entered  the  vessels  of  the  tumor. 
This  small  growth,  however,  has  so  stimulated  the  uterus  that  it 
has  grown  to  a  length  of  five  inches,  and  its  walls  are  at  least 
an  inch  and  a  quarter  thick.  In  like  manner,  the  growths  which 
project  into  the  uterine  cavity  bring  with  them  a  remarkable  in- 
crease of  the  womb,  and  this  not  due  to  the  mere  distension  of  the 
organ  by  the  substance  contained  within  its  cavity,  but  to  the 
actual  growth  of  its  tissue  and  unfolding  of  its  muscularity,  such 
as  takes  place  in  pregnancy,  and  even  in  those  rare  cases  where 
the  development  of  the  ovum  goes  on  external  to  the  womb  itself. 
In  these  cases,  however,  the  womb,  after  a  certain  period,  con- 
tracts upon  and  expels  the  tumor  or  polypus  from  its  cavity,  or 
the  tumor  passes  out  of  it  quietly  and  imperceptibl}^,  with  which 
occurrence  the  further  increase  of  the  organ  not  only  conies  to  a 
standstill,  but  its  size  diminishes,  so  that  not  infrequently  a  large 
polypus  maybe  found  connected  with  a  uterus  whose  dimensions 
fall  below  the  natural  standard.  Hence  it  is  that  the  instances  in 
which  the  womb  acquires  the  largest  size  are  not  those  in  which 
the  tumor  hangs  down  by  a  pedicle  into  its  cavity,  but  those  in 
which  its  development  takes  place  into  the  substance  of  one  or 
other  uterine  wall ;  and  the  organ  thus  increased  in  bulk  some- 
times attains  the  size  of  a  child's  head;  and  its  cavity  as  measured 
by  the  uterine  sound,  may  be  found  to  equal  four,  five,  or  six 
inches  in  length. 

It  is  a  matter  rather  of  idle  curiosity'  than  of  practical  utility  to 
determine  the  number  of  these  growths  that  may  exist  in  any  one 
uterus,  or  the  size  to  which  they  may  attain.'  They  are  seldom 
eolitary,  sometimes  they  are  very  numerous ;  and  they  are  usually 
present  in  the  greatest  number  on  the  peritoneal  surface  of  the 
womb,  while  it  is  rare  to  find  more  than  one  projecting  at  the 
same  time  into  the  cavity  of  the  organ.  This,  however,  is  prob- 
ably due  to  the  circumstance  that  there  is  not  room  for  more  than 
one  tumor  at  a  time  within  the  cavity  of  the  womb,  for  it  is  not 
a  very  uncommon  thing,  some  months  after  the  removal  of  one 
growth,  to  find  another  occupying  the  same  situation,  producing 

'  Walter's  Dissertation,  already  quotccl,  ^§  11  and  12.  and  pp.  27-30;  and  Jlcisg- 
nor,  op.  cit.,  vol.  ii,  pp.  Ki-lfl,  contain  references  to  the  most  rcniurkablc  cases  of 
largo  or  numerous  fibrous  tumors. 


220  NUMBER   AND    SIZE    OF   FIBROUS   TUMORS: 

the  same  symptoms,  and  calling  once  more  for  a  recourse  to  the 
same  operation. 

With  reference  to  the  size  of  these  growths,  we  encounter  wide 
diiFerences  again  in  this  respect,  instances  being  on  record  of  their 
attaining  to  such  dimensions  as  to  weigh  even  eighty  pounds;  and 
the  Aveight  of  the  growth  in  the  remarkable  case  delineated  by 
Walter  was  seventy-four  pounds.^  These  unquestionably  are  quite 
exceptional  instances,  but  they  are  worth  bearing  in  mind,  as  show- 
ing that  in  a  diagnostic  point  of  view  the  mere  size  of  the  tumor 
is  not  to  be  relied  on  in  discriminating  between  growths  from  the 
uterus  and  those  proceeding  from  the  ovary. 

There  are  very  few  ailments  in  the  course  of  which  nature  does 
not  make  some  eftbrts,  often,  indeed,  imperfect  and  unsuccessful 
efforts,  at  cure.  In  the  case  of  fibrous  tumors,  there  are  five  dif- 
ferent modes  in  which  this  attempt  is  made.  Either  the  pedicle 
undergoes  a  process  of  gradual  attenuation,  and  then  gives  way,  the 
tumor  thus  becoming  detached  from  the  uterus;  or  more  rarely,  a 
portion  of  its  investment  becomes  ulcerated  or  dies,  and  the  growth 
graduallv  shells  out  from  the  sheath  of  cellular  membrane  which 
contained  it;  or  a  change  takes  place  in  its  substance,  the  exact 
nature  of  which  is  not  quite  understood,  it  becomes  disintegrated, 
dies,  and  is  got  rid  of  piecemeal;  or  a  different  change  occurs, 
similar  to  what  we  see  in  other  morbid  products, — the  tumor 
undergoes  the  cretaceous  transformation,  and  though  not  elimi- 
nated from  the  womb,  it  ceases  to  stand  in  any  vital  relation  to  it, 
and  the  symptoms  Avhich  it  once  produced  diminish,  or  altogether 
disappear. 

Nothing  can  be  simpler  than  the  j^rocesses  by  which  these 
tumors,  when  growing  within  the  uterine  cavity,  may  become 
detached  from  their  connections  and  eventually  expelled,  though 
m}^  own  experience  does  not  lead  me  to  believe  that  any  of  them 
are  of  frequent  occurrence.  It  may  happen,  however,  either  that 
the  pedicle,  by  constant  traction  of  the  growth,  becomes  thinner 
and  thinner,  till  at  length  it  gives  way,  or  that  the  margins  of  the 
OS  uteri,  tightly  constricting,  strangulate  it,  or  that  in  its  violent 
expulsive  efforts,  the  uterus  snaps  the  slender  stalk  of  the  out- 

1  Op.  cit.  Though  in  this  case  the  whole  tumor  was  of  solid  texture,  still  in 
some  instances  the  enormous  dimensions  of  these  growths  have  been  due  to  cyst 
formation,  and  the  accumulation  of  a  large  quantity  of  fluid  in  their  interior.  This 
fluid  has  sometimes  amounted  to  many  pints,  and  the  distinct  fluctuation  to  which 
it  gave  rise  has  led  to  the  disease  being  taken  for  ovarian  dropsy,  and  to  the  patient 
being  tapped  for  its  relief.  No  instance  of  it  has  come  under  my  own  observation  ; 
but  the  impression  left  on  my  mind,  by  reading  the  various  recorded  cases  of  it,  is, 
that  the  disease  is  essentially  different  from  ordinary  fibrous  tumor,  since,  in  addi- 
tion to  one  or  two  cysts  of  very  great  size,  a  number  of  small  cysts  seem  always  to 
have  been  present  in  their  immediate  vicinity,  and  entering  into  the  structure  of 
the  more  solid  portions  of  its  growth.  The  cases,  in  short,  seem  to  be  instances  of 
fibro-cysHc  disease  of  the  uterus,  and  as  such  call  for  special  investigation,  rather 
than  ordinary  fibrous  tumors,  in  whose  substance  cysts  have  accidentally  formed. 
See,  in  addition  to  the  references  given  by  Paget,  op.  cit.,  vol.  ii,  p.  138,  Kiwisch, 
op.  cit..,  vol.  i,  p.  455,  and  Chiari,  op.  cit.,  p.  404. 


THEIR     SPONTANEOUS     CURE.  221 

growtli.^  This  detachment  of  the  tumor,  by  the  giving  way  of  its 
pedicle,  is  not  limited  to  cases  in  which  it  grows  into  the  cavity 
of  the  womb,  but  is  also  occasionally,  though  very  rarely,  observed 
in  instances  where  the  tumor  has  sprung  from  the  peritoneal  sur- 
face of  the  womb.  In  the  only  case  of  the  kind  which  has  come 
under  my  own  notice,  the  tumor  had  arisen  from  the  posterior 
uterine  wall,  and  had  projected  into  the  interspace  between  the 
uterus  and  rectum,  which  continental  writers  commonly  speak  of 
as  the  space  of  Douglas.  Though  perfectly  detached  from  the 
uterus,  however,  the  tumor,  which  was  of  the  size  of  a  wahiut, 
had  not  fallen  loose  into  the  peritoneal  cavity,  but  was  held  in  its 
position  by  false  membrane  passing  between  the  uterus  and 
rectum;  and  I  believe  that  in  almost  all  recorded  instances  of  the 
complete  detachment  of  a  fibrous  tumor  from  the  outer  surface  of 
the  womb,  the  outgrowth  has  been  retained  in  a  similar  manner 
close  to  the  part  whence  it  originally  sprang. 

Another  mode  by  which  fibrous  tumors  are  sometimes  got  rid 
of,  is  the  disintegration  of  their  tissue,  and  tlieir  subsequent  ex- 
pulsion. Tliis  process  seems  to  be  one  of  death  of  the  tumor;  but 
the  mode  in  which  it  is  brought  about  is  not  by  any  means  clearly 
understood.  It  is  not  a  process  of  inflammation,  nor  one  of  its 
ordinary  results.  The  fibrous  tumor,  when  attacked  by  inflamma- 
tion, presents  a  vivid  rose-red  color,  and  shows  a  greatly  increased 
vascularity;  while  local  pain  and  the  general  signs  of  inflammation 
attend  the  process  during  the  patient's  life.  The  disintegration 
of  the  tumor,  on  the  contrary,  takes  place  unattended  by  symp- 
toms which  could  lead  to  a  suspicion  of  what  is  going  on;  and 
the  outgrowth  becomes  soft,  and  breaks  down  into  a  dirty  putri- 
lage.  This  change  is  not  very  unusual  in  the  lower  part  of  fibrous 
l^olypi,  when  they  project  through  the  os  uteri  into  tlie  vagina. 
Tlie  mucous  membrane  covering  this  part  becomes  ulcerated,  and 
being  thus  deprived  of  its  most  important  source  of  nutrition,  the 
adjacent  portion  of  the  tumor  loses  its  vitality;  the  cellular  tissue 
binding  the  bundles  of  its  fibres  together,  dies  first,  and  such  a 
growth  may  sometimes  be  found  firm  and  solid,  and  presenting 
all  the  ordinary  characters  of  a  fibrous  tumor  at  its  upper  part, 
but  lower  down  split  up  into  a  number  of  shreds  or  packets  of 
fibres  connected  together  by  a  dirty  decaying  matter.  By  degrees, 
these  firmer  fibres  themselves  soften,  and  the  process  of  decay  ex- 
tending further  and  further,  the  whole  growth  may  come  away 
imperceptibly;  or,  on  attempting  to  remove  the  polypus,  we  may 
be  sui'prised  to  find  that  what  had  once  been  a  very  firm  mass,  is 
now  so  soft  that  the  hooks  by  which  we  endeavor  to  draw  it 
down,  tear  out — that  nature,  in  short,  has  anticipated  us,  and  that 
in  a  few  more  days  or  weeks  she  will  have  completed  her  operation. 

1  A  very  clabornte  paper  on  this  suhjoct,  containing  an  enumeration  of  twenty- 
four  cases,  collected  from  ditVerent  sources,  was  publisiied  by  M.  Marchal  do  Calvi 
in  the  Annates  de  la  Chirurgie,  August,  1843. 


222     '  SOFTENING    OF    FIBROUS     TUMORS. 

It  is  not,  however,  in  these  cases  only  that  the  death  of  a  fibrous 
tumor  takes  place.  The  same  process  may  go  on  in  the  tumor, 
while  still  completely  within  the  cavity  of  the  womb,  and  while 
still  of  inconsiderable  size.  On  examining  the  womb  of  a  woman 
sixty-three  years  old,  and  who  was  not  known  to  have  suffered 
from  any  symptoms  of  uterine  disease,  the  organ  was  found  de- 
formed by  eight  fibrous  tumors  growing  from  its  outer  surface, 
which  altogether  made  up  a  mass  three  times  the  size  of  the 
healthy  womb.  One  of  these  tumors,  as  large  as  a  pigeon's  egg, 
was  connected  with  the  posterior  uterine  wall  only  by  peritoneum 
and  a  very  slender  pedicle  of  cellular  tissue,  and  would  probably 
in  a  very  short  time  have  become  completely  separated,  while 
many  other  tumors  were  undergoing  the  calcareous  change,  and 
were  thus  in  process  of  cure.  On  laying  open  the  cavity  of  the 
womb,  it  was  found  to  bo  occupied  by  a  growth  of  the  size  and 
shape  of  a  sugared  almond,  1.25  inch  long  by  .9  of  an  inch  broad. 
On  its  free  surface  it  was  covered  by  the  uterine  mucous  mem- 
brane; but  it  was  imbedded  for  about  a  fourth  of  its  thickness  in 
the  uterine  wall,  from  which  it  was  separated  by  a  distinct  envel- 
ope of  dense  cellular  tissue,  such  as  surrounds  fibrous  tumors  in 
general.  It  was  of  a  dark,  almost  melanotic  color,  through  the 
greater  part,  thongli  not  the  whole  of  its  substance,  and  looked  as 
if  blood  were  infiltrated  into  the  substance  of  a  softening  fibrous 
tumor;  for  enough  of  its  tissue  still  remained  to  show  its  real 
nature,  even  irrespective  of  the  evidence  aftbrded  by  numerous 
small  fibrous  tumors,  varying  in  size  from  that  of  a  pea  to  that 
of  a  bean,  which  were  imbedded  in  the  uterine  walls. 

Hnd  this  person  lived  a  little  longer,  one  of  two  things  would 
doubtless  have  occurred, — either  the  elements  of  the  softened  out- 
growth would  have  been  absorbed,  or  its  cellular  investment  would 
at  some  point  have  given  way,  and  a  slight  discharge,  apparently 
of  coagulum,  would  have  been  the  sole  evidence  of  the  ailment 
from  which  the  patient  had  suffered,  and  of  the  means  by  which 
nature  had  wrought  for  its  removal.  AVhether  without  any  such 
previous  change  in  its  tissue,  fibrous  tumors  are  ever  completely 
removed  by  absorption,  is  a  question  that  I  am  unable  to  answer 
from  my  own  observation.  I  should  quite  believe  in  the  possibility 
of  the  occurrence,  though  my  impression  is  that  softening  and 
disintegration  usually  precede  the  removal  of  the  tumor,  and  that 
almost  invariably  it  is  not  absorbed,  but  is  expelled  in  its  softened 
state,  and  piecemeal,  from  the  cavity  of  the  womb. 

Whether  in  health  or  in  disease,  there  is  a  general  analogy 
between  nature's  modes  of  proceeding,  even  in  cases  apparently 
the  most  diverse,  which  it  is  both  interesting  and  instructive  to 
study.  The  tuberculous  bronchial  gland  is  softened,  its  invest- 
ment is  absorbed,  a  communication  is  opened  with  the  air-tube, 
and  the  diseased  matter  is  expelled;  or  when  this  cannot  be  accom- 
plished, another  change  in  its  element  takes  place;  the  gland 
shrinks,  its  substance  grows  harder  and  harder,  chemical  activities 


THEIR     CALCIFICATION.  223 

are  set  to  work,  and  a  few  masses  of  calcareous  matter  unexpect- 
edly discovered  close  to  the  bronchi  of  some  person  who  liad  died 
in  a  good  old  age,  tell,  not  infrequently,  that  in  his  youth  he  was 
the  subject  of  a  disease  which  usually  tends  to  destroy,  and  to 
destroy  speedily,  those  whom  it  attacks. 

Just  the  same  kind  of  changes  occur  in  fibrous  tumors  of  the 
womb.  We  have  already  studied  the  process  of  softening,  by 
which  their  removal  is  sometimes  brought  about:  a  process  of 
hardening  by  calcareous  deposit  in  their  substance  is  still  more 
common.  This  deposit  sometimes  takes  place  merely  in  the  \)e- 
ripher}'  of  the  tumor,  which  thus  receives  a  calcai'eous  investment 
or  shell,  its  interior  remaining  unaltered.  This,  however,  is  very 
unusual,  though  it  is  less  rare  to  find  incipient  calcification  of  the 
interior  of  the  tumor,  while  the  change  of  its  surface  is  complete. 
The  most  common  form  is  that  in  which  irregular  masses  like 
coral  are  deposited  in  various  parts  of  the  tumor,  whence  they  may 
be  separated  by  maceration,  or  which  make  up  in  the  case  of  the 
smaller  tumors  almost  the  entire  mass.  Now  and  then,  too,  this 
alteration  goes  on  to  the  same  extent  even  in  the  larger  growths, 
and  they  become  converted  into  a  substance  of  stony  hardness, 
which,  as  is  the  case  with  a  tumor  in  the  Museum  of  the  Middlesex 
Hospital,  may  receive  as  smooth  a  polish  at  the  hands  of  the  lapi- 
dary as  any  geological  specimen.  The  growths  which  proceed 
from  the  outer  surface  of  the  womb,  where  nutrition  is  usually  the 
least  active,  are  those  in  which  this  change  most  commonly  takes 
place.  Still  the  rule  is  by  no  means  without  exception,  as  a  tumor 
projecting  into  the  cavity  of  the  womb  sometimes  undergoes  this 
alteration,  and  being  at  length  expelled  from  the  uterus,  constitutes 
the  so-called  osseous  concretions,'  the  origin  and  nature  of  which 
were  once  a  puzzle  to  observers.  It  is,  I  imagine,  almost  super- 
fluous to  say  that  these  tumors  contain  none  of  the  elements  of 
true  bone,  that  the  change  which  takes  place  in  them  is  unaccom- 
panied by  the  formation  of  bone  cartilage ;  that  in  short  it  is  due 
to  a  chemical  rather  than  to  a  physiological  process,  and  like  the 
so-called  ossification  of  the  arteries,  is  an  evidence  of  enfeebled 
vitality,  not  of  active  nutrition.^ 

The  only  other*question  of  importance  concerning  the  pathology 
of  fibrous  tumors  of  the  uterus,  is  that  of  their  relation  to  ma- 
lignant disease,  and  the  possibility  of  their  degeneration  into 
carcinomatous  structures.  Nothing  but  the  imperfect  means  of 
observation  possessed  in  former  days  would  have  allowed  this  ques- 
tion to  remain  so  long  undecided ;  but  while  hard  cancer  was  be- 
lieved to  be  a  common  form  of  uterine  disease,  and  every  induration 

1  There  are  some  sjood  drawings  illustrative  of  those  changes  in  (ihrous  tumors 
in  Hooper's  Morbid  Anaiomy  of  the  Humfin  Ufcrxs,  4to.,  London,  18o2,  ])hitc  vii. 

"  See  on  this  subject  the  remarks  of  Professor  Bidder  at  p.  42  of  Walter's  Dis- 
serfaflon,  who  believes  in  the  occasional  presence  of  true  bone  ;  wliile  Henle  also, 
AUcjeincinc  AiKiioiuic,  \).  8n'.t,  stales  that  he  has  diseovrred  cartilage  corjiuscles  in 
them  ;  a  statement  which  Vogel,  in  Wagner's  Hatidbuch  der  Physinlogic,  vol.  i,  p. 
823,  does  not  corroborate. 


224         '  INFLUENCE     OFAGEON 

of  the  cervix  was  regarded  as  scirrhous,  it  is  not  surprising  that 
hard  tumors  should  have  been  believed  to  be  at  least  of  kindred 
nature.  It  may,  however,  be  now  positively  asserted  that  no  such 
degeneration  of  a  fibrous  tumor  ever  talq^s  place ;  and  further, 
that  though  fibrous  tumors  do  not  exclude  carcinoma,  they  yet  are 
not  associated  together  with  any  special  frequency.^ 

Fibrous  tumors  are  generally  regarded,  and  I  believe  with  truth, 
as  the  most  frequent  of  all  organic  diseases  of  the  womb,  though 
I  cannot  pretend  to  state  the  fact  numerically,  for  the  reasons 
which  have  been  already  referred  to  as  vitiating  the  statistics  of 
hospital  practice.  Strange  as  it  seems,  too,  the  results  of  post- 
mortem examinations  are  confiicting;  on  the  one  hand  we  have  the 
statement  on  Bayle's  authority,  that  every  fifth  woman,  after  the 
age  of  thirty-five,  lias  fibrous  tumors  in  her  uterus;  and  on  the 
other  hand,  the  allegation  of  M.  Pichard,^  that  they  were  met 
with  only  seven  times  in  800  examinations  made  by  himself  or  by 
M.  Lair.^  Mr.  Pollock,^  in  a  paper  read  before  the  Mcdico-Cliirur- 
gical  Society,  states  that  of  583  uteri  examined  by  himself  and  his 
predecessor  at  St.  George's  Hospital,  265  were  diseased,  and  in 
thirty-nine  of  them  fibrous  tumors  were  present,  while  cancer  ex- 
isted in  only  thirty-eight.  The  value  of  these  statements  is,  how- 
ever, not  a  little  diminished  by  their  referring  to  females  of  all 
ages,  from  birth  up  to  old  age.  Ecpially  unsatisfactory  are  the 
data  given  by  MM.  Braun  and  Chiari,^  according  to  whom  out  of 
2494  post-mortem  examinations  of  both  sexes,  twenty-five  instances 
were  found  of  the  presence  of  fibrous  tumors  of  the  uterus.  Of 
seventy  instances  in  which  1  have  examined  the  uterus  of  women 
who  died  after  puberty  of  other  than  uterine  diseases,  seven  pre- 
sented fibrous  tumor  of  the  uterus.  From  these  data  we  arrive  at 
nothing  more  definite  than  the  general  conclusion  that  fibrous  tu- 
mors of  the  uterus  are  very  frequent,  probably  more  frequent  than 
cancerous  disease  of  that  organ. 

The  data  of  which  we  are  possessed  with  reference  to  the  age 
of  patients  affected  with  fibrous  tumors,  though  very  scanty,  are 
yet  more  satisfactory,  because  more  definite.  Twenty-four  post- 
mortem examinations  of  Braun  and  Chiari,  and  nine  cases  of  my 

1  Dr.  Lee,  in  his  CHnical  Reports  of  Uterine  and  Ovarian  Diseases,  relates  one  case 
of  the  coexistence  of  a  calcareous  fibrous  tumor  and  malignant  ulceration  of  the 
uterine  cavity,  p.  176,  Case  V;  and  one  case  of  the  presence  of  the  two  has  come 
under  my  own  notice.  Chiari's  figures,  indeed,  would  lead  to  the  belief  that  fibrous 
tumors  of  the  womb  are  associated  with  a  special  liability  to  malignant  disease, 
since  in  twenty-live  examinations  of  patients  sufiering  from  them,  two  presented 
also  cancer  of  the  womb,  one  cancer  of  the  mamma  and  lung,  and  six  cancer  of 
other  organs,  op.  cit.,  p.  404.  I  know  of  no  other  data,  however,  which  would  lead 
to  the  same  conclusion. 

2  Diet,  des  Sciences  Medicales,  8vo.,  Paris,  1813;  Article  Corj^s  Fibreux  de  la 
Matrice,  p.  73. 

3  Des  Abus  de  la  Cauterisation,  ^-c,  dans  les  Maladies  de  la  Matrice,  8vo.,  Paris, 
1846,  Table  at  the  end. 

*  Lancet,  Feb.  7,  1852,  p.  155. 

Klinik  der  Geburtshiife  und  Gyndkologie,  2d  part,  Erlangen,  1853,  p.  397. 


PRODUCTION    OF    FIBROUS    TUMORS.  225 

own,  yield  the  following  result  as  to  the  age  of  the  subjects  in 
whom  the  tumors  were  found: 

2  age  not  stated. 

1  was  aged  24  years ;  and  she  died  of  puerperal  peritonitis. 

3  were  aged  between  30  and  40  years. 
14         "  "  40    "    50     " 

4  "  "  50  "  60  " 
7  "  "  60  "  70  " 
1          "               "  70    '• 

1  "  "  80 

33 

In  many  of  these  cases,  however,  the  tumors  had  doubtless  ex- 
isted for  many  years,  and  we  are  therefore  concerned  rather  with 
the  age  at  which  patients  first  complain  of  those  symptoms  to 
which  fibrous  tumors  give  rise,  though  even  then  the  disease  itself 
has  probably  existed  in  many  instances  for  months,  or  even  years, 
before  it  attracted  notice. 

Braun  and  Chiari  have  stated  the  ages  of  thirty-seven  patients 
who  applied  for  relief  at  the  great  hospital  at  Vienna  on  account 
of  fibrous  tumors  of  the  uterus  not  including  polypi ;  and  if  to 
these  be  added  ninety-six  cases  wdiich  have  come  under  my  own 
observation,  w^e  obtain  a  total  of  one  hundred  and  thirty-three,  of 
which — 

26  were  between  20  and  30  years  of  age. 
44      "     30  "  40    " 
47      "     40  "  50    " 
15      "     50  "  60    " 
1      "     72  years. 

133 

The  above  proportions  differ  in  no  important  degree  trom  those 
obtained  by  Malgaigne'  on  a  comparison  of  fifty-one  cases  of  fibrous 
poly})US  of  the  uterus,  from  wdiich,  if  twenty-two  cases  of  my  own 
be  added,  we  obtain  the  following  result : 

From  26  to  30  years 4 

"     30  to  40      "         24 

"     40  to  50      "         30 

"     50  to  60      "         7 

"     60  to  70      "         3 

"     70  to  74      "         5 

73 

If,  however,  instead  of  taking  the  age  at  which  the  patient  first 
applied  at  the  hospital,  we  draw  our  conclusions,  as  we  ought 
ratlier  to  do,  from  the  period  at  which  the  symptoms  characteristic 
of  the  disease  first  manifested  themselves,  it  will  be  seen  that 
fibroustuniors  and  fibrous  polypi  are  an  aftection  incidental  to  the 

1  Dcs  Polypes  Uierins,  Thise  dc  Concours,  4to.,  Paris,  1833,  p.  12. 

15 


Age  of  patients. 

First  came  und( 

Under 

20  years,     . 

Between 

20  and  30  years, 

11 

a 

30    "    40" 

II 

40 

it 

40    "    50 

II 

50 

II 

50    "    60 

(I 

15 

Above 

60  years 

1 

226  SYMPTOMS    OF 

season  of  sexual  vigor  much  oftener  than  to  the  period  of  its 
decline. 


26 

48 

34 

5 

1 

117  117 

It  has  hecn  asserted  on  Bayle's  authority  that  single  women  are 
more  liahle  to  these  tumors  than  those  who  are  married,  but  my 
own  observation  does  not  bear  out  the  statement ;  for  of  ninety-six 
women  affected  with  non-pedicuhited  fibrous  tumors,  eighty-two 
were  married;  or  incUiding  the  cases  of  fibrous  polypi,  of  one 
hundred  and  eighteen,  ninety-nine  were  married.  The  prepon- 
derance of  married  women  is  so  considerable  as  to  show,  I  think 
conclusively,  in  spite  of  the  comparative  smallness  of  the  numbers, 
that  the  non-exercise  of  the  sexual  functions  has  no  influence  in 
predisposing  to  the  disease. 

Taking  leave,  then,  of  that  attempt  to  ascertain  the  cause  of  this 
affection,  which  in  the  case  of  all  diseases  we  are  so  disposed  to 
make,  and  from  which  we  so  seldom  arrive  at  any  satisfactory 
result,  we  may  now  pass  to  the  very  important  inquiry  concerning 
the  consequences  that  these  tumors  produce  and  the  symptoms  that 
they  occasion. 

First  of  all  it  may  be  premised  that  sometimes  these  tumors 
are  attended  by  no  symptoms  at  all ;  that  they  exist  for  many  years 
without  producing  any  inconvenience  whatever.  Illustrations  of 
this  fact  are  attbrdcd  us  by  the  discovery  of  fibrous  tumors  after 
death  in  the  uteri  of  women  whose  sexual  system  had  never  shown 
any  sign  of  disturbance;  by  our  accidentally  ascertaining  their 
presence  when  examining  a  patient  for  some  other  purpose  ;  or  by 
the  sudden  supervention  of  symptoms  calling  our  attention  to  the 
state  of  the  womb,  and  revealing  the  existence  of  a  large  fibrous 
tumor,  whose  o-rowth  must  have  been  e-oins:  on  for  vears.  As 
might  be  expected,  the  constancy  of  the  symptoms  is  generally 
proportionate  to  the  intimacy  of  the  relation  l)etween  the  tumor 
and  the  uterus.  The  growths  which  proceed  from  the  outer  sur- 
face of  the  womb  often  produce  no  symptoms  except  such  as  are 
due  to  their  mechanical  pressure  upon  adjacent  organs ;  whilst 
those  which  are  imbedded  in  the  uterine  substance  almost  always 
disturb  the  functions  of  the  organ,  even  before  they  have  attained 
any  considerable  size ;  and  the  polypi  or  growths  which  occupy 
the  cavity  of  the  womb  attract  attention  almost  from  the  first  by 
the  hemorrhage  which  they  occasion.  Some  relation,  too,  subsists 
between  the  general  activity  of  the  sexual  sj-stem  and  the  exercise 
of  its  highest  functions  on  the  one  hand,  and  the  severity  of  the 
symptoms  of  fibrous  tumor  on  the  other.  It  is  thus  that  in  v»'omen 
advanced  in  life,  and  whose  menstruation  has  ceased,  the  effects 


FIBROUS    TUMORS.  227 

of  fibrous  tumors  are  usually  less  serious  than  in  younger  women. 
It  is  thus,  too,  that  these  growths  may  produce  so  little  incon- 
venience as  to  be  scarcely  suspected  so  long  as  a  woman  remains 
single,  but  may  become  the  occasion  of  much  suffering  as  soon  as 
she"  marries,  and  as  sexual  intercourse  occasions  the  frequently 
increased  afflux  of  blood  towards  the  womb.  The  bearing  of  these 
facts  upon  our  prognosis  and  treatment  must  be  sufficiently  obvious 
even  now,  but  will  be  still  more  apparent  after  we  have  examined 
the  symptoms  of  this  affection  more  in  detail. 

Those  fibrous  tumors  which  hang  by  a  pedicle  into  the  uterine 
cavity,  and  which  are  commonly  called  uterine  polypi,  are  attended 
by  one  invariable  and  characteristic  symptom, — viz.,  hemorrhage. 
Since,  then,  their  diagnosis  is  comparatively  easy,  and  since  their 
treatment  differs  from  that  which  is  generally  practicable  in  the 
other  forms  of  fibrous  tumor,  we  will  postpone  their  further  con- 
sideration for  the  present;  and  my  remarks  will  be  understood  to 
have  reference  to  those  varieties  of  fibrous  tumor  which  are  either 
imbedded  in  the  uterine  substance,  or  which  project  from  its  peri- 
toneal surface.  Menstrual  disorder,  uterine  hemorrhage,  pain, 
dysuria,  and  more  rarely  difficult  defecation,  are  the  more  im- 
portant symptoms  of  fibrous  tumors,  though  from  being  present 
in  various  degrees,  and  in  varying  combinations,  they  often  leave 
room  for  much  doubt  as  to  the  nature  of  the  affection  to  which 
they  are  due. 

The  following  are  the  principal  results  deduced  from  a  compari- 
son of  ninety-six  cases  of  fibrous  tumor  of  the  uterus,  of  which  I 
have  preserved  a  sufficient  record : 

In  eight  of  the  ninety-six  cases  menstruation  had  already  ceased 
when  the  patients  came  under  my  observation,  but  in  two  of  them 
considerable  hemorrhage  occurred  from  the  uterus  at  irregular 
intervals,  in  two  such  hemorrhage  occurred  in  bi\t  small  quantity, 
and  in  four  it  did  not  take  place  at  all. 

In  thirty  more  cases  the  menstrual  function  was  not  disturbed 
at  all,  and  in  twenty-four  of  them  there  was  no  intercurrent  uterine 
hemorrhage  at  other  times ;  but  in  six  patients  hemorrhage  occa- 
sionally took  place,  which,  however,  had  no  relation  in  the  time 
of  its  occurrence  to  the  menstrual  function. 

In  the  remaining  fifty-eight  cases  menstruation  was  more  or  less 
seriously  disturbed,  being 

Excessive, in  30  cases. 

"         and  painful, "10  " 

"  "    irregular,      .     ..."     5  " 

Painful, "5  " 

"       and  irregular, <'     2  " 

Irregular, "2  " 

Scanty,     . "4  " 

58 

It  appears  {hen  that  in  forty-five  out  of  eighty  eight  cases  in 
which  menstruation  had  not  ceased,  it  uas  either  excessive  in 
quantity,  or  over-frequent  in  recurrence,  or  both;  while  in  fifteen 


228  INFLUENCE    OF    FIBROUS    TUMOKS 

instances  tlie  function  was  performed  with  excessive  pain ;  and 
only  in  four  instances  did  the  quantity  of  blood  lost  at  the  period 
fall  below  that  to  which  the  patient  was  accustomed  when  in 
health. 

In  forty-four  cases  hemorrhage  from  the  uterus  occurred  at  other 
times  than  those  of  menstruation  ;  an  accident  which  took  place 

After  the  cessation  of  the  menses, in    4  cases. 

Coincided  with  menorrhagia  or  over-frequent  menstrua- 
tion,     "32  " 

"  "    painful  menstruation, "2  " 

"  "         "        and  irregular  menstruation,  .     .     "     1  " 

"  "    irregular  menstruation, "1  " 

"  "    no  disorder  of  menstruation,     .     ..."     4  " 

44 

In  sixty-five  cases,  pain  was  complained  of  at  other  periods  than 
those  of  menstruation.  This  pain  varied  greatly  in  its  severity, 
its  situation,  and  its  continuance;  some  patients  describing  it  as  a 
burning  sensation,  others  as  a  sense  of  bearing  down,  while  others 
again  seemed  to  suffer  from  it  in  paroxysms  of  almost  intolerable 
anguish.  This  pain  in  thirteen  of  the  sixtj'-five  instances  coin- 
cided with  painful  menstruation  ;  but  in  four  cases  of  dysmenor- 
rhoea,  pain  was  not  experienced  at  other  than  the  menstrual  epochs. 
Menstruation  had  already  ceased  in  six  of  the  cases  in  which  pain 
was  experienced,  and  in  the  remaining  forty-six  was  performed 
without  suffering,  and  in  nineteen  of  the  number,  without  dis- 
order of  any  kind. 

There  were,  moreover,  thirty-five  instances  in  which  the  patient 
suffered  from  dysuria ;  either  from  pain  in  voiding  urine,  or  from 
difiiculty  in  its  discliarge,  or  from  frequent  desire  to  pass  it;  while 
four  times  complaints  were  made  of  difficulty  in  defecation  :  but 
none  of  these  sensations  could  be  referred  so  distinctly  to  the 
seat  of  the  tumor  or  to  its  size  as  might  beforehand  have  been 
expected. 

The  influence  of  fibrous  tumors  in  modifying  the  rate  of  fecun- 
dity is  very  remarkable,  and  shows  itself  both  in  diminishing  the 
number  of  conceptions,  and  also  in  increasing  the  i:)roportion  of 
pregnancies  which  come  to  a  premature  termination.  Of  the 
ninety-six  cases  on  which  these  observations  are  founded,  eighty- 
two  were  those  of  married  women ;  of  these  twenty  were  sterile, 
while  the  remaining  sixty-two  had  given  birth  to  one  hundred 
and  twenty-four  children,  and  had  miscarried  forty-eight  times. 
Thirty-one  of  the  sixty-two  had  had  but  one  pregnancy,  which  in 
the  case  of  twenty-one  had  gone  on  to  its  full  period ;  in  ten  had 
terminated  prematurely  by  miscarriage.  It  is  true  that  five  women 
had  given  birth  to  three  children  each,  four  to  four,  three  to  five, 
one  to  eight,  one  to  nine,  and  one  to  eleven,  respectively;  but  in 
all  but  three  of  these  instances,  the  tumor  either  grew  from  the 
fundus,  or  was  situated  external  to  the  posterior  uterine  wall,  and, 
as  far  as  could  be  ascertained,  did  not  involve  the  substance  of 
the  womb.     "We  shall  hereafter  see  that  even  when  proceeding 


ON    MENSTRUATION.  229 

from  this  situation,  fibrous  tumors  of  the  uterus  often  render 
pregnancy,  and  labor,  and  the  puerperal  state,  periods  of  great 
hazard ;  but  it  is  eas}'  to  understand  that  when  the  growths  pro- 
ceed from  the  exterior  of  the  womb,  they  may  not  interfere  with 
the  mere  term  of  utero-gestation. 

The  symptoms  of  fibrous  tumors  for  the  most  part  come  on  by 
degrees,  so  that  the  patient  cannot  narrowly  define  the  commence- 
ment of  her  ilhiess,  but  speaks  of  a  gradual  increase  in  the  abun- 
dance of  her  menstruation,  or  of  the  discomforts  which  attend  it, 
or  of  some  painful  sensation  at  first  scarcely  perceived,  becoming 
by  little  and  little  more  and  more  importunate,  until  at  length, 
when  driven  to  seek  relief,  she  first  became  aware  of  the  existence 
of  the  tumor.  To  this  rule,  however,  exceptions  are  by  no  means 
uncommon  ;  m\d  in  twenty-one  of  ninety-six  cases  the  symptoms 
came  on  suddenly,  some  grave  accident  at  once  forcing  itself  on 
the  attention  of  the  patient,  who  had  previously  imagined  herself 
quite  well.  In  eleven  of  these  twenty-one  cases,  it  was  hemor- 
rhage, in  five  inability  to  void  the  urine,  such  as  to  call  for  the 
use  of  the  catheter,  which  first  excited  the  patient's  alarm,  and 
five  times  it  was  intense  abdominal  pain,  though  it  by  no  means 
follows  that  the  first  symptoms  should  continue  throughout  the 
most  prominent.  Lastly,  I  may  add  that  in  eleven  instances  the 
accidental  discovery  of  a  tumor  in  the  abdomen,  was  the  first  in- 
dication that  the  patient  received  of  the  existence  of  an  affection 
which  for  years  must  have  been  in  slow  course  of  development. 

If,  now,  we  endeavor  to  picture  to  ourselves  the  history  of  a 
case  of  fibrous  tumor  of  the  uterus,  we  shall,  I  think,  find  our 
sketch  to  be  sometliing  of  the  following  kind  :  A  person,  probably 
a  little  past  the  prime  of  womanhood,  but  at  an  age  at  which  the 
sexual  functions  are  still  actively  performed,  becomes  causelessly 
the  subject  of  menorrhagia,  which  may  or  may  not  be  attended 
with  pain.  The  hemorrhage  is  at  first  readily  suppressed  by  rest 
and  ordinar}'  precautions,  but  it  afterwards  returns  on  every  slight 
exertion,  and  at  length  comes  on  without  any  cause  at  all,  or  con- 
tinues from  one  menstrual  period  to  another,  so  that  the  patient 
loses  all  count  of  the  proper  mcnstraal  epochs.  She  does  not 
experience  that  general  constitutional  disturbance  which  almost 
always  accompanies  idiopathic  menorrhagia,  but  sufi'ers  merely 
from  the  loss  of  blood  and  its  direct  results,  while  in  the  intervals 
between  the  attacks  of  bleeding,  she  is  seldom  troubled  by  leu- 
corrhoca,  and  never  by  any  ofi'ensive  discharge.  Cou])led  with 
the  hemorrhage,  sometimes  from  the  very  first,  generally  witliin 
a  few  months  from  its  outset,  various  sensations  of  pain  or  dis- 
comfort are  experienced  in  the  lower  part  of  the  abdomen,  and 
the  neighborhood  of  the  womb.  Among  these  sensations  of  dis- 
comfort, that  of  a  frequent  desire  to  pass  water  is  one  of  the  most 
frequent.  The  abiding  pain  is  seldom  of  great  intensity;  unlike 
the  pain  of  chronic  uterine  inflammation,  it  is  not  such  a^  to  render 
sudden  changes  of  posture,  the  sitting  on  a  hard  seat,  or  jolting 
on  a  rough  road  almost  intolerable ;  it  does  not  even  preclude 


230  CONDITIONS     OF    THE    UTERUS 

sexual  intercourse.  On  the  other  hand,  it  is  not  a  sharp  lancin- 
ating pain  like  that  of  carcinoma,  but  is  a  dull  aching,  or  burning, 
or  throbl)ing,  not  in  general  very  difficult  to  bear,  though  now 
and  then  there  are  associated  with  it  occasional  attacks  of  suttering 
evidently  neuralgic  in  character,  intense  in  their  severity,  and 
generally  accompanied  by  violent  expulsive  eflbrts. 

Any  symptoms  of  this  kind  should  raise  a  suspicion  in  our  minds 
as  to  the  probable  existence  of  a  fibrous  tumor  of  the  uterus,  while 
neither  the  comparative  youth  nor  the  advanced  age  of  the  patient, 
neither  the  sudden  supervention  of  the  symptoms,  nor  their  very 
slow  development,  should  be  allowed  to  negative  this  suspicion, 
or  to  bias  our  minds  with  reference  to  a  question  which  a  careful 
examination  can  alone  decide.  In  any  such  case,  and  indeed  in 
every  instance  where  there  is  the  least  possibility  of«the  existence 
of  a  tumor  of  any  kind,  it  is  necessary  to  begin  by  a  careful  ex- 
amination of  the  abdomen.  The  tumor  formed  by  a  fibrous  growth 
is  generally  very  firm,  nodulated,  and  uneven,  seldom  mesial,  but 
so  often  situated  considerably  to  one  side  of  the  abdomen,  that  its 
position  alone  is  not  of  much  value  as  a  means  of  discriminating 
between  it  and  tumor  of  the  ovaries.  The  latter  may,  however, 
generally  be  distinguished  by  their  smooth  surface  and  spherical 
contour,  as  well  as  by  a  certain  degree  of  elasticity,  which  is 
usually  distinguishable  in  them,  even  though  they  should  yield 
no  distinct  sense  of  fluctuation.  On  making  a  vaginal  examina- 
tion, the  condition  will  be  found  to  vary  very  much,  according  to 
the  position  and  relations  of  the  tumor.  If  any  tumor  can  be  felt 
in  the  abdomen,  the  first  point  to  ascertain  is  the  relation  borne 
by  it  to  that  of  the  uterus,  to  determine  whether  pressure  on  the 
one  is  immediately  conmiunicated  to  the  other;  since  thereby 
some  clue  may  be  obtained  as  to  the  probability  of  its  connection 
with  the  substance  of  the  womb  on  the  one  hand,  or  with  the 
uterine  appendages  on  the  other.  The  ovarian  tumor,  when 
once  it  has  risen  out  of  the  pelvis,  almost  always  draws  the  uterus 
up  with  it,  while  this  change  of  position  seldom  takes  place  when 
the  growth  proceeds  from  tlie  womb  itself.  The  posterior  uterine 
wall  is  the  most  common  seat  of  fibrous  tumors,  inasmuch  as  they 
were  present  there  in  thirty  eight  out  of  ninety-six  cases  ;^  and  in 
twelve  of  the  number  could  not  be  discovered  in  any  other  part  of 
the  uterus  that  was  accessible  to  examination.  Hence  we  gen- 
erally find  a  firm  body  often,  but  not  always,  uneven,  occupying 
more  or  less  of  the  posterior  part  of  the  pelvic  cavity,  carrying 
the  uterus  forwards  towards  the  symphysis  pubis,  and  frequently 
more  or  less  completely  retroverting  the  organ;  in  which  case  it 
is  usually  displaced  from  the  mesial  line,  so  that  the  os  uteri  is  to 
be  found  near  to  the  pubo-iliac  synostosis  on  one  or  other  side. 

1  The  result  thus  obtained  bj'  examination  during  life  tallies  tolerably  closely 
with  that  arrived  at  by  Mr.  Lee,  from  a  comparison  of  various  preparations  in  the 
Museums  of  the  metropolis;  who  found  that  in  twenty-two  out  of  seventy-four 
cases  the  growth  sprang  from  the  posterior  wall  of  the  body  or  neck  of  the  uterus. 
See  Saflford  Lee,  On  Tumors  of  the  Uterus^  8vo.,  London,  1847,  p.  2,  table  i. 


IN    CASES    OF    FIBROUS    TUMOR.  281 

The  OS  uteri  itself  is  generally  small,  circular,  and  healthy;  the 
tissue  of  the  cervix  smooth  and  healthy,  or,  at  the  most,  only 
somewhat  turgid  and  hard,  from  the  frequent  afflux  of  hlood  to- 
wards the  organ.  If  the  tumor  be  very  small,  springing  from  just 
behind  the  cervix,  the  diagnosis  between  it  and  retroflexion  of 
the  uterus  is  a  matter  of  much  difficulty,  and  harder  still  is  it  to 
make  out  the  distinction  between  anteflexion  of  the  uterus  and  a 
fibrous  tumor  of  its  anterior  wall,  the  possibility  of  which  must 
not  be  lost  sight  of  in  the  confessed  rarity  of  its  occurrence.  If 
the  tumor  is  within  the  uterine  cavity,  or  imbedded  in  its  walls, 
the  results  of  an  examination  will  of  course  be  different;  the 
uterus  will  be  found  larger,  heavier,  and  less  movable  than 
natural;  its  lower  segment  may  be  distended  by  the  tumor,  and 
in  that  case  will  not  be  unlike  the  form  which  is  assumed  by  the 
pregnant  womb,  though  the  lips  of  the  uierus,  instead  of  present- 
ing the  development  characteristic  of  the  gravid  state,  wnll  be 
found  mechanically  thinned  by  the  pressure  of  the  tumor.  The 
cervix  uteri,  too,  in  such  cases  not  infrequently  disappears  long 
before  the  growth  has  attained  such  a  size  as  by  its  prominence 
in  the  abdomen  to  simulate  the  state  of  the  womb  when  gestation 
is  half  completed.  If,  however,  the  tumor  does  not  thus  project 
into  tlie  uterine  cavity,  its  diagnosis  will  be  much  more  difficult, 
for  a  large,  a  somewliat  hard,  and  a  but  partially  movable  uterus, 
will  l)e  all  that  is  at  first  apparent,  all  perhaps  that  even  a  repeated 
examination  may  discover.  Still,  even  here,  the  unaltered  orifice 
of  the  womb,  the  absence  of  tenderness  of  its  cervix,  and  of  any 
thickening  about  the  roof  of  the  vagina,  will  suffice  to  show  that 
neither  has  inflammation  of  its  appendages  fixed  the  organ  in  its 
position,  nor  has  inflammation  of  its  substance  or  its  cervix  in- 
creased its  size  and  weight.  The  sound  may  also  show  the  cavity 
of  the  uterus  to  be  elongated;  and  I  believe  that  an  enlarged,  and 
heavy,  and  somewhat  hard  uterus,  coupled  with  the  causeless  oc- 
currence and  frequent  return  of  uterine  hemorrhage,  while  the 
OS  and  cervix  uteri  are  healthy,  are  almost  always  characteristic 
of  fibrous  deposit  in  the  uterine  substance.  It  is,  I  imagine, 
scarcely  necessary  to  say  that  not  infrequently  we  come  to  this 
opinion  rather  by  the  exclusion  of  all  other  possible  sources  of 
similar  symptoms  than  by  the  positive  evidence  afl:brded  by  any 
single  sign  pathognomonic  of  this  affection. 

It  must  remain,  however,  for  our  task  at  the  next  Lecture  to 
pass  in  review  the  various  anomalies  in  the  symptoms  of  fibrous 
tumors  of  the  uterus,  and  to  study  the  different  circumstances 
which  may  render  our  diagnosis  difficult  or  doubtful. 


232  DIAGNOSIS    OF    FIBROUS    TUMORS 

LECTURE    XVI. 

UTERINE  TUMORS  AND  OUTGROWTHS. 

Fibrous  Tumors  ; — their  diagnosis,  and  exceptional  character  of  their  symp- 
toms in  some  cases.  Occasional  difficulty  of  distinguishing  between  them  and 
ovarian  tumors.  Menstrual  irregularity  and  subsequent  sudden  hemorrhage 
has  raised  suspicion  of  miscarriage.  Sudden  suppression  of  urine  in  some 
cases  ;  its  import.  Difficulty  of  distinguishing  between  flexions  and  tumor  of 
the  uterus.  Possibility  of  mistaking  for  cancer.  Cases  characterized  by  in- 
tense pain.  Diagnosis  between  pregnancy  and  fibrous  tumor,  and  difficulty 
of  discovering  former  when  complicated  with  latter. 

Prognosis ;  progress  generally  slow ;  illustrative  table.  Influence  of  pregnancy 
and  labor;  dangers  which  attend  them,  and  why. 

We  have  hitherto  looked  at  the  symptoms  of  fibrous  tumors  of 
the  uterus  only  as  they  appear  in  the  simplest  cases,  with  nothing 
to  obscure  or  distort  their  characteristic  features.  In  the  study  of 
all  diseases,  however,  our  concern  is  at  least  as  much  with  the 
exception  as  with  the  rule ;  and  if  we  would  not  fall  into  gross 
errors,  we  must  be  as  ready  to  undo  the  tangled  web,  and  to  find 
in  the  midst  of  it  the  clue  that  may  lead  us  right,  as  we  should  be 
quick  to  follow  the  signs  which  point  out  the  plainest  path,  and 
render  even  a  moment's  doubt  .almost  impossible. 

Some  of  the  rarer  cases,  then,  must  next  engage  us ;  and  I  must 
try,  even  at  the  risk  of  wearing  out  your  patience,  to  describe  some 
of  the  many  circumstances  which  may  cause  us  to  hesitate  in  the 
diagnosis  of  fibrous  tumors  of  the  uterus. 

In  enumerating  the  symptoms  of  this  afi^'ection,  it  has  already 
been  mentioned,  that  while  hemorrhage  very  often  attends  it,  the 
occurrence  is  by  no  means  constant.  It  may,  however,  happen 
that  missing  on  some  occasion  this,  which  is  one  of  the  most 
characteristic  signs  of  the  disease,  we  may  begin  to  doubt  its 
nature,  and  to  question  whether  the  tumor  which  we  discover  is 
not  connected  with  the  ovary  rather  than  with  the  womb  itself,  I 
do  not  know  any  certain  means  of  avoiding  error  in  such  cases, 
but  refer  to  them  for  the  sake  of  impressing  on  you  the  fact,  that 
the  mere  absence  of  hemorrhage,  or  even  a  condition  of  scanty 
menstruation,  does  not  negative  the  possibility  of  the  existence  of 
fibrous  tumor ;  just  as,  I  may  add,  on  the  other  hand,  very  profuse 
hemorrhage  sometimes  occurs  in  instances  where  the  tumor  is 
unquestionably  connected  with  the  ovaries. 

The  kind  of  difficulty  which  presents  itself  in  some  instances  in 
distinguishing  between  tumors  of  the  uterus  and  tumors  of  the 
ovaries,  and  the  considerations  which  guide  us  to  a  solution  (pos- 
sibly indeed  not  always  a  correct  one)  of  the  question,  will  perhaps 
be  best  understood  by  the  following  sketch  of  the  history  of  a 
woman,  aged  thirty-nine,  who  was  admitted  under  my  care  into  St. 
Bartholomew's  Hospital,  in  April,  1851.  She  had  been  married 
twenty  years,  but  for  eighteen  had  been  a  widow,  her  only  child 


OF    UTERUS.  233 

Laving  been  born  a  year  after  marriage.  Her  menstruation,  which 
commenced  at  fourteen,  had  always  been  regular,  and  unattended 
by  any  considerable  inconvenience,  while  it  had  at  no  time  been 
excessive.  She  first  noticed  a  swelling  in  the  right  side  of  the 
abdomen  between  three  and  four  months  before  she  came  under 
my  notice  ;  and  this  tumor  had  since  gradually  increased  in  size. 
Since  she  first  perceived  the  tumor,  she  had  had  two  or  three 
attacks  of  pain  in  the  back,  followed  by  retention  of  urine ;  while 
her  bowels  were  often  constipated,  and  she  frequently  required 
aperient  medicine.  Her  general  health,  however,  was  not  seriously 
impaired. 

The  abdomen  measured  thirty-six  inches  and  a  half  at  the 
umbilicus,  forty-one  inches  and  a  half  two  inches  lower  down. 
The  abdominal  integuments  were  loose,  and  contained  a  good  deal 
of  fat.  A  solid  movable  tumor  occupied  the  abdomen,  extend- 
ing from  low  down  on  the  left  side  of  the  pelvis,  across  the  mesial 
line,  reaching  on  the  right  side  to  an  inch  and  a  half  above  the 
umbilicus,  and  to  within  three  inches  of  the  right  crista  ilii,  but 
not  dipping  down  into  the  right  side  of  the  pelvis  as  it  did  on  the 
left.  This  tumor  was  solid,  non-fluctuating,  and  its  surface  was 
somewhat  nodulated.  At  its  upper  part,  and  at  the  right  side  near 
the  umbilicus,  one  portion  of  the  tumor,  a  sort  of  oflshoot  as  it 
seemed,  was  movable  upon  the  other  larger  part  of  the  growth. 
On  examining  per  vaginam,  the  finger  at  once  came  upon  a  firm 
globular  tumor  occupying  the  pelvic  cavity,  and  dipping  down  to 
within  an  inch  of  the  outlet.  At  the  anterior  and  right  part  of 
the  tumor  a  depression  could  be  felt,  somewhat  like  the  os  uteri, 
though  the  finger  could  not  be  made  to  enter  it ;  but  in  no  other 
situation  could  the  least  trace  of  an  opening  be  discovered.  A 
grooved  needle  was  introduced  with  some  difiiculty  per  vaginam 
into  the  tumor,  but  no  trace  of  any  fluid  was  obtained. 

In  this  case  the  circumstances  which  favored  the  supposition 
that  the  tumor  was  ovarian,  were  its  large  size,  the  alleged  rapidity 
of  its  growth,  the  fact  of  its  situation  not  being  mesial,  and  the 
absence  of  uterine  hemorrhage  during  its  growth.  On  the  other 
hand,  the  mere  size  of  the  tumor  is  not  conclusive,  since,  as  you 
know,  a  fibrous  tumor  of  the  uterus  sometimes  attains  to  enormous 
dimensions ;  while  further,  the  early  stages  of  its  growth  might  all 
the  more  readily  be  overlooked,  owing  to  the  large  quantity  of  fat 
in  the  abdominal  walls.  Moreover,  in  spite  of  the  frequency  of 
uterine  hemorrhage  as  a  symptom  of  fibrous  tumors  of  the  uterus, 
it  is  an  accident  by  no  means  of  constant  occurrence,  and  in  some 
of  the  largest  fibrous  tumors  that  have  come  under  my  notice,  the 
only  symptoms  produced  have  been  purely  mechanical.  It  is  very 
unusual  to  find  so  large  an  ovarian  tumor  without  some  sense  of 
fluctuation  ;  the  uneven  nodulated  surface,  and  the  mobility  of  one 
portion  of  the  tumor  upon  the  other  is,  moreover,  consonant  with 
what  one  observes  in  tumors  of  the  uterus  rather  than  in  those  ot 
the  ovary.  The  results  of  vaginal  examination,  the  solid  tumor, 
the  altered  condition  of  the  lower  segment  of  the  uterus,  the 

\ 


234  DIAGNOSIS     OF    FIBROUS    TUMORS. 

absence,  or  at  least  the  impossibility  of  discovering  the  os  uteri, 
unless  it  were  represented  by  the  small  depression  which  I  have 
mentioned,  and  lastly,  the  result  of  puncture  with  the  exploring 
needle,  all  seem  to  warrant  the  conclusion  that  the  tumor  was 
uterine,  and  not  ovarian. 

In  addition  to  these  means  of  diagnosis,  which  will  be  found  more 
or  less  applicable  in  other  cases,  the  position  of  the  patient  during 
a  vaginal  examination  is  a  matter  of  considerable  importance.  If 
a  woman  assumes  the  usual  attitude,  the  tumor  naturally  falls 
towards  the  left  side,  carrying  the  uterus  with  it.  To  ascertain 
correctly  the  relations  between  the  womb  and  the  tumor,  the 
examination  should  be  made  with  the  patient  lying  on  her  back, 
even  though  it  should  be  necessary,  as  very  probably  it  may  be,  for 
th'e  sake  of  making  a  complete  examination,  to  alter  her  position, 
and  to  place  her  afterwards  on  her  side. 

I  should  perhaps  add  that  the  diagnosis  between  uterine  and 
ovarian  tumors  is  sometimes  still  more  obscured  by  the  presence 
of  fluid  in  the  abdominal  cavity.  Some  degree  of  ascites  is  indeed 
far  from  unusual  in  cases  of  ovarian  disease ;  but  its  coexistence 
with  fibrous  tumor  of  the  uterus  is  so  rare  that  it  may  possibly 
be  forgotten.  Twice,  however,  I  have  had  occasion  to  tap  the 
abdomen  in  cases  where  a  tumor  was  supposed  to  be  ovarian,  and 
it  was  only  on  a  careful  examination,  after  the  evacuation  of  the 
fluid,  that  its  real  nature  became  api)arent,  and  that  the  tumor 
was  ascertained  to  be  connected  with  the  uterus,  and  not  with  the 
ovary.  Since,  then,  the  two  conditions  may  be  present,  it  is  wise 
to  abstain  from  forming  a  positive  opinion  as  to  the  nature  and 
relations  of  any  solid  tumor  which  may  be  felt  in  the  abdomen 
when  much  distended  b}-  fluid,  and  to  wait  till  tapping  has  re- 
moved the  fluid,  and  rendered  the  tumor  accessible  to  a  thorough 
examination. 

Another  deviation  from  the  ordinary  characters  of  the  disease  is 
seen  when  its  symptoms  set  in  with  great  suddenness,  those  symp- 
toms being  generally  either  hemorrhage,  or  retention  of  urine. 
The  sudden  hemorrhage  is  sometimes  assumed  to  be  due  to  niis- 
carriage,  and  this  upon  grounds  as  slender  as  a  mere  impression 
upon  the  patient's  mind  that  she  was  pregnant,  often  indeed  a 
hope,  rather  than  a  belief,  that  this  was  the  case.  The  great  safe- 
guard against  this  class  of  mistakes  consists  in  never  taking  a 
patient's  statement  as  to  the  existence  of  pregnancy  for  granted, 
but  in  always  questioning  her  closely  with  reference  to  the  date 
of  her  previous  menstruation,  and  the  evidence  of  her  alleged  con- 
dition ;  and  if  this  be  done,  it  will  not  infrequently  turn  out  that 
an  assertion  made  most  positively,  is  nevertheless  unsupported  by 
a  single  tittle  of  proof.  But  further,  the  hemorrhage  excited  by  a 
fibrous  tumor  is  usually  more  profuse  than  that  of  an  early  abor- 
tion— is  often  unattended  by  pain,  while  when  pain  is  present,  it 
is  not  of  the  same  kind,  nor  do  the  pain  and  the  bleeding  cease 
at  the  same  time  as  they  do  when  miscarriage  has  occurred.  The 
causeless  return  of  the  bleeding  in  cases  of  fibrous  tumors,  gene- 


SUDDEN    ONSET    OF    THEIR     SYMPTOMS.  235 

rally  removes  the  doubt  wliicli  miglit  have  been  felt ;  while  if  au 
exaiiiination  be  made  per  vaginam,  though  in  both  cases  the  womb 
will  be  heavier  than  natural,  yet  the  developed  lips  of  the  os,  its 
patulous  condition  and  soft  texture,  after  a  recent  miscarriage, 
differ  much  from  the  firm  tissue  of  the  neck  of  the  womb  in  the 
other  case,  its  undeveloped  lips,  its  small  and  scarcely  open  orifice. 

The  other  mode  in  which  the  symptoms  sometimes  suddenly 
manifest  themselves  is  in  the  supervention  of  great  difficulty  in 
voiding  the  urine,  or  in  the  occurrence  of  retention  of  urine  such 
as  to  necessitate  the  use  of  the  catheter. 

The  occasional  retention  of  urine  is  an  occurrence  by  no  means 
infrequent,  independent  of  organic  disease,  in  women  of  an  hysteri- 
cal temperament,  and  cannot  of  itself  be  regarded  as  characteristic 
of  any  one  affection  in  particular.  It  is,  however,  well  to  l)ear  it 
in  mind,  as  being  sometimes  the  first  indication  of  the  existence 
of  fibrous  tumors  of  the  uterus,  while  both  it  and  dysuria,  and  very 
frequent  micturition,  are  less  frequent  attendants  upon  ovarian 
tumors,  except  in  those  cases  in  which  both  ovaries  are  afi'ected, 
and  one  occupies  the  pelvis,  while  the  other  fills  the  cavity  of  the 
abdomen.  The  reason  for  this  difterence  between  ovarian  and 
uterine  tumors  is,  I  believe,  to  be  found  in  the  tendency  of  the 
tumor  of  the  ovary  to  rise  out  of  the  pelvic  cavity,  while  the  fibrous 
tumor  of  the  uterus  still  continues  in  its  original  situation  ;  and, 
as  it  enlarges,  either  presses  against  the  neck  of  the  bladder,  or 
carries  the  uterus  more  and  more  forwards  till  it  comes  to  press 
U[)on  that  organ,  to  irritate  it,  and  even  mechanically  to  interfere 
with  the  discharge  of  its  contents. 

This  interference  with  the  functions  of  the  bladder  is  usually 
most  remarkable  in  those  instances  in  which  the  tumor  proceeds 
from  the  anterior  surface  of  the  uterus;  and  I  relate  the  following 
case  both  in  illustration  of  this  fact,  and  also  of  another  to  which 
reference  has  already  been  made,  namely,  the  manner  in  whicli 
some  unwonted  cause  of  uterine  congestion  may  at  once  call  into 
painful  distinctness  a  train  of  symptoms  previously  little  felt,  per- 
lu4»s  even  scarcely  suspected. 

A  woman,  aged  thirty-five,  married  for  eleven  mouths,  but  who 
had  never  been  pregnant,  was  admitted  under  my  care  in  Decem- 
ber, 1852.  Previous  to  her  marriage,  liabitual  dysmenorrha^a  had 
been  the  only  form  of  ill  health  from  which  she  had  suffered,' but 
since  then  she  had  been  troubled  with  frequent  desire  to  jjasy  water, 
and  constant  aching  i>ain  in  the  loins,  aggravated  by  walking. 
The  urine  was  either  natural,  or  else  threw  down  a  precipitate  of 
the  lithates.  The  case  seemed  at  first  as  though  it  were  simply 
one  of  uterine  congestion  after  marriage,  and  local  leeching 
brought  slight  and  temporary  relief  to  the  symptoms.  On  exami- 
nation per  vaginam,  however,  the  os  uteri  was  found  to  be  directed 
much  backwards, — it  was  very  slightly  0[)en  ;  while  a  tumor  of  a 
rounded  form  was  distinctly  felt  in  front  of  the  cervix,  pressing 
immediately  against  the  bladder,  and  the  sound  introduced  into 
the  bladder  encountered  this  same  obstacle  to  its  introduction, 


236  DIAGNOSIS    OF    FIBROUS    TUMORS 

whicli  was  overcome  only  after  a  little  manipulation,  though  no 
evidence  was  obtained  at  any  time  of  the  existence  of  disease  of 
that  organ.  The  position  of  the  os  uteri,  and  the  circumstance  of 
its  almost  complete  closure,  while  in  cases  of  flexion  of  the  womb 
it  is  nearly  always  open,  were  two  of  the  reasons  which  led  me  to 
regard  the  case  as  one  of  uterine  tumor,  not  of  anteflexion  of  the 
uterus.  In  other  instances  of  tumors  of  the  anterior  uterine  wall, 
I  have  observed  a  nearly  equal  degree  of  irritability  of  the  blad- 
der, but  coupled  with  hemorrhage  and  other  characteristic  symp- 
toms of  fibrous  tumors  of  the  uterus,  which  in  this  case  were 
absent. 

The  discrimination  between  fibrous  tumors  of  the  posterior 
uterine  wall  and  retroflexion  of  the  uterus,  is  often  attended  by  at 
least  as  much  difficult}^  as  that  between  the  two  opposite  states  of 
anteflexion  and  tumor  of  the  anterior  wall.  Tliese  cases  illustrate 
one  remarkable  fact,  to  which  reference  has  already  been  made 
when  I  was  speaking  of  flexions  of  the  uterus,  namely,  the  want 
of  any  constant  relation  between  the  amount  of  mechanical  pres- 
sure on  the  rectum,  and  the  degree  of  difficulty  in  defecation. 
Sometimes,  indeed,  the  presence  of  a  tumor  so  large  as  almost  com- 
pletely to  fill  the  cavity  of  the  pelvis,  will  be  attended  by  scarcely 
any  difficulty  in  the  expulsion  of  the  freces,  while  in  another  case, 
a  growth  of  but  small  size  will  be  accompanied  by  pain  and  difii- 
culty  in  emptying  the  bowel,  and  the  presence  of  mucus  in  the 
evacuations  will  give  unmistakeable  proof  of  the  irritation  to  which 
it  has  given  rise.  The  comparatively  slow  growth  of  a  fibrous 
tumor,  and  the  time  consequently  given  for  the  adaptation  of 
parts  to  their  new  relations,  no  doubt  goes  far  to  explain  the  gen- 
eral absence  of  any  serious  difficulty  in  defecation ;  it  occurred 
only  in  four  of  the  ninety-six  instances  on  which  my  remarks  are 
founded.  Nothing,  however,  is  more  variable  than  the  amount  of 
pain  attendant  upon  uterine  ailments;  and  causes  acting  through 
tlie  medium  of  the  general  system,  as  well  as  others  more  local  in 
their  influence,  often  excite  intense  suffering  from  some  disease 
of  the  womb  which  had  existed  for  months  or  years  before  without 
occasioning  severe  pain,  perhaps  even  without  producing  serious 
inconvenience. 

Neither  the  amount  of  pain,  nor  the  degree  of  difficulty  in  de- 
fecation, can  be  taken  as  affording  an}'  clue  to  the  solution  of 
the  question,  whether  we  have  to  do  with  a  retroflected  womb,  or 
with  a  fibrous  tumor  of  the  posterior  uterine  wall.  The  exact 
relations  of  the  tumor,  the  fact  of  the  tissue  of  the  cervix  uteri 
passing  over  into  that  of  the  tumor, — a  characteristic  of  flexion  of 
the  womb  which  the  experienced  touch  will  generally  be  able  to 
appreciate, — the  state  of  the  os  uteri,  and  the  results  of  the  intro- 
duction of  the  uterine  sound,  which  will  remove  the  misplacement 
and  inform  us  of  the  weight  of  the  uterus  (supposing  always  that 
we  can  introduce  it,  though  that  is  sometimes  impracticable),  are 
generally  sufficient  to  keej)  us  from  error.  In  spite  of  all  care, 
however,  we  may  sometimes  meet  with  cases  in  which  we  shall 


FROM    CANCER    OF    THE    UTERUS.  237 

find  it  a  most  difficult  matter  to  arrive  at  a  certain  diagnosis. 
Need  I  say  that  the  importance  of  a  correct  diagnosis  consists,  in 
these  cases,  not  in  its  leading  us  to  the  adoption  of  any  special 
plan  of  treatment,  but  rather  in  its  enabling  us  to  remove  much 
needless  anxiety,  to  assure  our  patient  that  there  may  be  some 
misplacement  of  the  womb,  but  that  there  is  no  disease  of  the 
organ,  nor  any  reason  for  anticipating  an  increase  of  suffering,  still 
less  for  apprehending  a  painful  and  lingering  illness. 

The  history  alone  of  fibrous  tumor  may  often  raise  the  suspicion 
that  the  patient  is  affected  with  cancer,  for  pain  and  hemorrhage 
may  both  be  present,  and  the  health  may  give  way  under  their 
continuance,  while  it  needs  but  inattention  to  cleanliness,  and  the 
allowing  the  coagula  to  remain  in  the  vagina  and  decay  there,  in 
order  to  produce  the  third  symptom, — offensive  discharge,  which 
is  so  often  looked  upon  as  almost  pathognomonic  of  malignant 
disease  of  the  womb.  A  vaginal  examination,  however,  seldom 
fails  to  clear  up  all  uncertainty ;  so  little  is  there  in  common  be- 
tween the  small  os,  the  thin  and  undeveloped  lips  which  coexist 
with  fibrous  tumor,  and  the  gaping  oj-ifice,  with  the  thickened, 
hard,  irregular,  and  nodulated  lips  that  characterize  cancer  of  the 
womb. 

Error,  however,  is  still  possible,  and  Dr.  ^lontgomery,  in  his 
valuable  paper,  to  which  reference  has  already  been  made,  men- 
tions some  instances  where  the  pressure  of  a  fibrous  tumor  just 
about  to  project  through  the  os  uteri  against  tlie  lower  segment 
of  the  womb,  and  the  consequent  alteration  in  the  condition  of 
the  cervix,  had  led  to  the  mistaken  supposition  that  cancer  existed. 
Care  ought  to  prevent  you,  I  think,  from  falling  into  this  mistake. 
More  difficult,  however,  is  the  diagnosis  between  cancer  of  the 
body  of  the  uterus  and  fibrous  tumor  of  the  organ  ;  and  tlie  risk 
is  considerable,  in  spite  of  much  watchfulness,  of  your  taking  the 
more  for  the  less  serious  disease.  When  speaking  of  cancer  of 
the  womb,  I  shall  shortly  have  occasion  to  refer  again  to  this  sub- 
ject. At  present  it  may  suffice  to  say  that  the  more  rapid  progress 
of  the  malignant  disease,  the  persistence,  tliough  not  of  necessity 
the  greater  abundance,  of  the  hemorrhage,  and  the  want  of  mo- 
bility of  the  uterus,  though  its  size  be  not  such  as  to  occupy 
com[)letely  the  pelvic  cavity,  are  some  of  the  more  important 
characters  by  which  we  may  usually  recognzie  that  rare  aflection — 
cancer  of  the  body  of  the  womb. 

Though  not  likely  to  induce  any  positive  error  of  diagnosis, 
there  is  yet  another  deviation  from  the  ordinary  symjitoins  of 
fibrous  tumors  of  the  uterus,  which  calls  for  some  notice.  It 
ha)»pens  now  and  then  that  they  are  accompanied  by  attat-ks  of 
pain  of  such  intense  severity  as  to  be  almost  unbearable,  the  ]>ain 
being  evidently  neuralgic  in  character,  ceasing  abru])tly,  returning 
causelessly,  and  being  but  little  amenable  to  any  kind  of  treat- 
ment. These  attacks  do  not  seem  to  be  dependent  on  the  size  of 
the  tumor,  nor  on  its  situation,  and  are  certainly  not  connected 
with  any  special  pressure  exerted  l)y  it  on  any  organ,  or  on  any 


238  DIAGNOSIS    OF    FIBROUS    TUMORS 

set  of  organs.  lu  one  case,  in  which  it  continued  for  years  to 
return  occasionally,  a  sense  of  weight  and  burning  referred  to  the 
womb  being  experienced  in  the  intervals,  the  tumor  was  imbedded, 
as  far  as  could  be  ascertained,  in  the  posterior  uterine  wall.  Men- 
struation was  irregular,  but  profuse ;  its  occurrence  had  no  inilu- 
ence  either  in  increasing  or  in  lessening  the  uterine  pain.  The 
patient  was  at  different  times  under  my  care  with  little  benefit, 
and  many  trials  were  made  of  preparations  of  iodine,  without  her 
being  able  to  continue  the  remedy.  At  length,  after  the  lapse  of 
four  years,  she  became  able  to  take  iodine  without  the  disturbance 
of  health  which  it  had  previously  occasioned,  and  after  about  six 
weeks'  continuance  of  it,  both  the  abiding  and  the  paroxysmal 
pain  were  greatly  lessened,  though  the  condition  of  the  tumor 
remained  unaltered. 

The  other  case  was  one  of  a  still  more  remarkable  character. 
A  stout,  tolerably  healthy-looking  woman,  but  whose  somewhat 
bloated  face  confirmed  the  suspicions  which  her  calling  as  the  wife 
of  a  publican  excited,  presented  herself  one  morning  at  the  out- 
patient room  of  St.  Bartholomew's  Hospital.  At  that  time  her 
appearance  and  manner  presented  every  sign  of  most  intense 
agony;  drops  of  perspiration  stood  on  her  forehead,  her  skin  was 
cold  and  clammy,  and  her  pul«e  feeble.  With  these  manifestations 
of  extreme  suftering,  there  were  associated  a  disposition  to  weep, 
and  also  a  good  deal  of  globus  hystericus.  After  being  some  little 
time  in  bed,  the  intense  pain  subsided,  and  she  then  gave  the  fol- 
lowing account  of  herself:  She  was  thirty-three  years  old,  had 
been  married  seventeen  years,  had  given  birth  to  one  live  child  at 
the  eighth  month,  and  had  miscarried  three  times  at  early  periods ; 
twelve  years  having  elapsed  since  her  last  miscarriage.  The  cata- 
menia  had  always  been  regular  in  their  return,  but  for  the  last  two 
years  the  discharge  had  been  more  profuse  than  before.  For  six- 
teen years  she  had  had  occasional  attacks  of  pain  similar  to  those 
from  which  she  suffered  when  she  came  under  my  notice,  but  the 
attacks  had  always  been  mitigated  by  cupping  and  leeching.  For 
eight  years,  however,  the  pain  had  returned  regularly  immediately 
after  tiie  cessation  of  menstruation,  and  had  continued  for  about  a 
week  after  each  period,  the  paroxysms  returning  every  two  hours, 
and  lasting  from  half  an  hour  to  an  hour.  Her  health  was  gene- 
rally best  for  a  week  before,  and  sometimes  during  menstruation, 
though  the  pains  had  greatly  increased  in  their  severity,  and  were 
sometimes  brought  on  by  exertion,  or  by  sexual  intercourse,  while 
rest  in  the  recumbent  posture  always  relieved  them.  The  patient 
complained  besides  of  a  sort  of  cramping  pain  during  micturition, 
and  of  diflicult  defecation,  as  if  from  some  substance  contracting 
the  passage  for  the  fseces.  When  the  pain  came  on  she  sat  up  in 
bed,  swaying  herself  from  side  to  side,  weeping  loudly,  complaining 
of  pain  like  the  throes  of  labor,  and  also  of  a  choking  sensation, 
all  of  which  subsided  by  degrees  in  the  course  of  about  half  an 
hour.  The  abdomen  was  full ;  its  size,  which  was  considerable, 
was  partly  due  to  fat  with  which  the  integuments  were  loaded ; 


WHEN  ATTENDED  BY  INTENSE  PAIN.         239 

on  laying  the  hand  npon  it,  spasm  of  the  abdominal  muscles  was 
immediately  excited ;  and  this  for  some  minutes  prevented  tiie 
attempt  to  determine  whether  any  tumor  was  seated  there  or  not, 
though  after  a  time  this  was  settled  in  the  negative.  The  uterus 
was  situated  low  down  in  the  axis  of  the  pelvic  outlet;  its  anterior 
lip  was  three-fourths  of  an  inch  longer  than  the  posterior ;  the 
tissue  of  the  cervix  was  healthy,  the  os  circular,  and  slightly  open.. 
Behind,  and  to  the  left  of  the  uterus,  and  extending  also  slightly 
in  front,  was  a  firm  uneven  nodulated  tumor,  tender  on  pressure, 
connected,  though  apparently  not  very  intimately,  with  the  uterus, 
but  which  w^as  ascertained  by  repeated  examinations,  and  by 
evidence  of  the  uterine  sound,  which  discovered  the  cavity  of 
the  organ  to  be  four  inches  and  a  half  long,  to  be  in  reality  an 
outgrowth  from  the  womb,  and  not  a  tumor  simply  connected 
with  its  appendages. 

At  first  quinine  was  given  in  large  doses  and  at  short  intervals, 
but  with  little  effect;  and  I  may  state  my  general  impression,  that 
quinine  oftener  fails  to  arrest  uterine  neuralgia  than  to  relieve  pain 
seated  in  other  systems  of  nerves.  Afterwards  the  pain  was  kept 
in  check  b}^  opium,  and  the  patient  left  the  hospital  relieved,  but 
not  more  than  might  be  expected  from  quiet,  a  regulated  diet,  and 
the  anticipating  each  attack  of  suffering  by  appropriate  treatment. 

The  most  frequent  and  the  most  important  exceptional  peculiari- 
ties of  these  growths  have  now  been  passed  in  review ;  but  refer- 
ence ought  perhaps  to  be  made  to  the  distinction  between  fibrous 
tumors  and  pregnancy,  and  to  the  discrimination  of  pregnancy 
when  it  coexists  with  tumors.  Of  the  two,  I  believe  the  latter  to 
be  far  the  more  difficult ;  and,  indeed,  when  we  find  the  size  of 
the  womb  obviously  increased  by  fibrous  outgrowths,  it  is  almost 
a  pardonable  error  to  attribute  to  them  the  whole  increased  bulk 
of  the  organ,  and  to  lose  sight  of  the  possibility  of  a  ph3'siological 
cause  having  a  share  in  the  production  of  the  enlargement.  No 
direction  can  be  laid  down  such  as  will  always  keep  from  error : 
the  best  safeguard  is  perhaps  to  be  found  in  our  making  it  a  rule 
for  our  guidance,  in  ever}'  case  of  doubtful  tumor,  to  prove  the 
non-existence  of  pregnancy  before  advancing  a  step  further  in 
forming  a  diagnosis.  It  is  to  be  remembered,  sadly  strange  as  it 
may  seem,  that  there  is  scarcely  any  disease,  however  forinidal)le 
or  however  loathsome,  in  spite  of  which  sexual  intercourse  and 
conception  may  not  take  place.  Vesico-vaginal  fistula,  the  most 
repulsive  disease  of  the  external  organs,  cancers  of  the  vagina  or  of 
the  uterus,  are  far  from  proving  the  bar  to  cohabitation  that  might 
be  ex[)ected — a  cohalntation  often  on  the  woman's  part  suljmitted 
to  with  pain  of  body  and  anguish  of  mind ;  for,  indeed,  it  is  in 
her  sex,  much  less  often  than  in  our  own,  that  "the  Centaur  not 
fabulous"  finds  its  aptest  illustrations. 

Ileferencc  has  already  been  made  to  the  different  condition  of 
the  womb  in  pregnancy  from  that  which  it  presents  when  enlarged 
by  fibrous  tumor;  and  the  dissimilar  state  of  the  lips  and  orifice 
of  the  womb,  and  the  different  consistence  of  its  eidarged  lower 


240  DIAGNOSIS    OF    FIBROUS    TUMORS. 

segment,  will  generally  suffice  to  keep  the  attentive  observer  from 
error.  It  is,  indeed,  from  relying  on  the  evidence  furnished  by 
some  one  or  two  symptoms  of  pregnancy,  and  not  taking  into  due 
consideration  the  counterproof  alForded  by  other  symptoms,  that 
mistakes  are  almost  always  committed.  The  uterus  is  found  en- 
larged, and  its  lower  segment  expanded ;  movements  supposed  to 
she  foetal  are  felt  by  the  patient,  and  a  sound  resembling  the  uterine 
souffle  is  perhaps  detected,  and  the  existence  of  pregnancy  is  at 
once  assumed;  no  account  being  taken  of  the  occurrence  of  hemor- 
rhage, of  the  non-development  of  the  uterine  lips,  and  of  those 
other  phenomena  which  ought  to  have  excited  suspicion ; — which, 
duly  weighed,  might  have  at  once  proved  the  case  to  be  merely 
one  of  uterine  tumor.  It  is  well  to  bear  in  mind  that,  although 
always  of  rare  occurrence,  it  yet  happens  more  frequently  in  cases 
of  fibrous  tumor  than  of  any  other  uterine  ailment,  that  a  sound 
is  perceptible  closely  resembling  the  uterine  souffle,  and  corre- 
sponding with  it  in  situation,  and  in  the  extent  of  surface  over 
which  it  is  heard.*  The  caution  which  this  fact  suggests  must  not 
be  lost  sight  of  in  any  case  of  doubtful  pregnancy. 

The  complication  of  fibrous  tumor  with  pregnancy  may  inter- 
fere very  seriously  with  the  detection  of  that  condition,  partly  by 
the  misplacement  of  the  womb  which  it  frequently  produces,  the 
consequent  alteration  in  the  form  of  the  organ,  and  the  difficulty 
that  it  may  give  rise  to  in  attempting  to  reach  the  os  uteri ;  and 
partly  by  the  impediment  which  the  deposit  itself  may  oiler  to  the 
occurrence  of  the  physiological  changes  in  the  orifice,  neck,  and 
lower  segment  of  the  womb. 

Some  time  since  a  case  was  under  my  observation  in  the  hospital, 
in  which  I  overlooked  the  existence  of  pregnancy;  and  I  will  re- 
late to  you  some  particulars  of  it,  as  illustrating  the  circumstances 
that  may  conspire  to  throw  you  off  your  guard,  and  to  obscure 
almost  completely  the  usual  symptoms  of  pregnancy. 

A  woman,  aged  thirty-eight,  who  had  been  married  twelve 
months,  but  had  never  been  pregnant,  stated  that  she  had  had 
tolerably  good  health,  and  had  menstruated  regularly  until  seven 
weeks  before  slie  applied  for  admission,  when  the  discharge  sud- 
denly ceased  after  exposure  to  cold.  Four  months  before  I  saw 
her  she  first  perceived  a  hard,  painless  swelling,  about  the  size  of 
an  egg:,  below  and  to  the  right  of  the  umbilicus,  and  this  increased 
until  it  had  attained  half  its  subsequent  size,  without  any  disturb- 
ance of  her  health.  Since  the  cessation  of  her  menses,  she  had 
suflered  from  pain  in  the  back  and  loins,  which,  slight  at  first,  had 

*  In  "Walter's  remarkable  case,  to  which  reference  has  already  been  made,  a  loud 
souffle  contributed  for  a  time  to  obscure  the  diagnosis.  Several  instances  of  loud 
uterine  souffle  coexisting  with  uterine  tumor,  and  independent  of  pregnancy,  are  re- 
lated by  J.  A.  H.  Depaul,  TraiU  d' Auscultation  Obstetricale,  8vo.,  Paris,  1847,  pp. 
209-222.  I  have  observed  it  in  one  only  out  of  the  ninety-six  cases  on  which  these 
remarks  are  founded.  In  this  instance,  too,  error  was  scarceW  possible,  for  the 
sound  was  accompanied  by  a  distinct  fremissement,  and  both  it  and  the  tremor 
seemed  to  be  seated  in  the  left  epigastric  artery  and  its  branches. 


DIAGNOSIS    OF    FIBROUS    TUMORS.  241 

by  degrees  become  very  severe,  and  at  length  compelled  her  to 
seek  for  medical  advice.  Leeching  and  rest  had  relieved  her  pain, 
but  the  tumor  gradually  increased  in  size.  Three  weeks  before 
her  admission,  a  discharge,  said  to  be  menstrual,  again  made  its 
appearance,  and  continued  I'or  a  week,  when  it  ceased  for  two 
days,  but  then  returned,  and  was  still  going  on  when  tlie  patient 
came  under  my  care. 

The  abdomen  was  occupied  by  a  tumor,  which  was  not  sym- 
metrical, but  more  prominent  on  the  right  than  on  the  left  side  of 
the  umbilicus,  reaching  up  to  about  its  level,  extending  to  within 
about  an  inch  and  a  half  of  the  left  crista  of  the  ilium,  and  com- 
pletel}'  occupying  the  right  iliac  region.  It  was  hard,  unyielding, 
seemed  about  the  size  of  an  infant's  head ;  was  tender  on  pressure 
upon  its  most  prominent  part.  On  examining  per  vaginam,  the 
linger  came  at  once  upon  a  spherical  body,  occupying  the  posterior 
half  of  the  pelvis,  and  pressing  the  neck  of  the  womb  closely 
against  the  symphysis  pubis.  This  tumor,  which  was  firm  though 
somewhat  clastic,  began  immediately  l)ehind  the  cervix  uteri, 
which  was  about  half  an  inch  long,  the  lips  soft,  and  the  os  open 
enough  to  admit  the  finger,  while  the  cervical  canal  was  not  closed, 
nor  could  any  mucous  plug  be  detected  in  it. 

After  the  patient's  admission,  there  was  very  little  hemorrhage 
from  the  uterus,  but  she  had  frequent  attacks  of  very  violent  pain 
of  an  expulsive  character.  Opiates  mitigated  the  severity  of  these 
attacks  and  controlled  their  frequency,  and  at  the  end  of  a  month 
the  patient  left  the  hospital  much  relieved,  her  abdomen  measuring 
thirty-three  inches  at  the  umbilicus,  as  on  the  day  of  her  admission. 

A  month  after  she  left  the  hos[)ital  she  was  prematurely  confined 
of  a  still-born  child  at  about  the  sixth  month  of  utero-gestation, 
and  her  recovery  after  her  lal)or  was  retarded  by  an  attack  of 
uterine  inflammation,  of  which  the  patient  spoke  as  having  been 
very  severe.  Nine  weeks  after  her  delivery  I  again  saw  her,  and 
found  her  uterus  low  down  and  fixed  in  the  pelvis,  the  enlarged, 
elongated,  and  much  thickened  cervix  being  closely  in  apposition 
witli  the  anterior  pelvic  wall,  while  a  large  tumor  connected  with, 
and  growing  out  of  the  posterior  uterine  wall,  com[)letely  filled 
the  pelvic  cavity,  and  greatly  contributed  to  the  immobility  of  the 
organ. 

It  were  time  wasted  to  dwell  at  length  on  the  causes  which 
rendered  the  diagnosis  of  pregnancy  so  difiicult  in  this  case,  or 
which  indeed  prevented  any  suspicion  of  it  being  entertained. 
Unsuspected  by  the  patient  herself,  some  of  its  symptoms  were 
doubtless  unnoticed  by  her;  while  the  continuance  of  a  discharge 
like  that  of  the  menses,  its  subsequent  suppression  for  a  short 
period,  its  reappearance  and  persistence  for  three  weeks  before 
she  was  received  into  the  hospital,  all  seemed  more  like  the  evi- 
dences of  disease  than  any  of  the  ordinary  results  of  pregnancy. 
Examination,  too,  detected  a  tumor  occupying  the  pelvic  cavity, 
and  which  was  clearly  a  fibrous  outgrowth.  This  very  tumor  pre- 
vented the  ordinary  changes  in  the  lower  segment  of  the  uterus 

16 


242  PROGNOSIS    IN    FIBROUS    TUMORS: 

from  taking  place,  and  thus  led  to  the  belief  that  uterine  disease, 
and  disease  alone,  existed.  You  know,  however,  that  a  correct 
diagnosis  implies,  not  simply  the  discovery  of  the  patient's  dis- 
ease, but  the  formation  of  a  right  joclgment  concerning  that 
patient  in  all  respects.  The  public  feel  as  little  respect  for  an  in- 
complete diagnosis  as  for  one  that  is  altogether  wrong. 

It  is  not  possible,  with  reference  to  any  disease  whose  progress 
is  so  variable  and  course  so  uncertain  as  that  of  uterine  fibrous 
tumor,  to  make  any  general  statement  concerning  the  prognosis 
that  we  should  form,  for  the  contingencies  are  very  numerons  by 
which  the  patient's  condition  may  be  modified.  Thus  much,  how- 
ever, may  be  stated  :  that  apart  from  the  risks  attendant  on  preg- 
nancy and  labor,  fibrous  tumors  do  not  tend  generall}',  nor  ever 
rapidly,  to  the  destruction  of  life,  though  they  undermine  a  person's 
health,  and  must  often  make  her  an  easy  prey  to  any  intercurrent 
disease.  In  only  one  out  of  the  ninety-six  cases  on  which  these 
observations  are  based  did  the  patient  die  of  hemorrhage,  and  the 
fatal  event  in  this  instance  occurred  nine  years  after  the  appear- 
ance of  the  first  symptoms  of  the  disease;  while  in  the  other  two 
fatal  cases  death  was  due  to  uterine  and  peritoneal  inflammation 
after  delivery.  The  subjoined  table  which  shows  the  duration  of 
the  symi)toms  at  the  time  when  the  patients  first  came  under 
my  observation,  illustrates  the  comparatively  slow  course  of  the 
affection. 


The  symptoms 

had  lasted  less 

than  . 

1 

year 

in  23 

between 

1 

and 

2 

years 

in     8 

II 

2 

— 

3 

"      5 

i< 

3 



4 

"   13 

(I 

4 

— 

5 

"    10 

<( 

5 

— 

6 

"      9 

<i 

6 

— 

7 

"     4 

i( 

7 

— 

8 

"     4 

i< 

8 



9 

"     2 

II 

9 

— 

10 

"     3 

<< 

10 

— 

11 

II     4 

II 

11 

— 

12 

"     3 

ii 

12 

— 

13 

"     2 

11 

13 

— 

16 

"     3 

for 

20 

"     1 

11 

23 

"     1 
In  1 

who  died  after  delivery,  the  existence  of  the  tumor  was  not 
suspected  till  labor  took  place.  — 

Total,  96 

Unlike,  then,  any  form  of  malignant  disease,  uterine  fibrous 
tumor  shows  no  constant  tendency  to  advance  or  to  increase;  and 
if  we  are  compelled  to  allow  that  medicine  furnishes  no  certain 
means  by  which  to  arrest  its  growth,  and  that  surgery  can  but 
seldom  be  called  to  our  aid,  it  is  yet  a  consolation  to  be  able  truth- 
full}^  to  assure  our  patient  that  the  much-dreaded  ailment  is  yet 
less  formidable  than  it  was  supposed  to  be,  much  less  so  than  it 
has  often  been  represented. 

I  purposely,  however,  excepted  one  contingency  when  mention 


INFLUENCE  OF  PREGNANCY  AND  LABOR.       243 

ing  the  comparatively  small  risk  to  life  from  fibrous  tumor  of  the 
uterus,  aud  spoke  of  the  disease  apart  from  the  dangers  that  attend 
upon  it  when  associated  with  pregnancy,  labor,  and  the  puerjieral 
state.  We  have  already  seen  that  the  existence  of  fibrous  tumors 
in  the  uterus  lessens  the  chances  of  conception,  and  it  is  fortunate 
that  it  does  so,  for  the  increased  afilux  of  blood  towards  the  womb 
which  pregnancy  occasions  is  almost  sure  to  accelerate  the  growth 
of  any  tumor  connected  with  it.  Pregnancy,  indeed,  when  it 
does  take  place,  often  has  a  premature  terniination  ;  for  the  pres- 
ence of  a  tumor  in  the  wall  of  the  uterus  interferes  with  the  regular 
development  of  the  organ,  and  thus  in  many  instances  abridges 
the  term  of  gestation.  Not  long  since  a  patient  was  under  my 
care,  in  whom  the  existence  of  a  tumor,  imbedded  in  the  left  wall 
of  the  uterus,  was  ascertained  soon  after  the  occurrence  of  an  ap- 
parently causeless  miscarriage.  Four  other  miscarriages  have  since 
successively  occurred,  and  no  other  reason  can  be  assigned  for 
them  than  that  which  the  uterine  tumor  suggests. 

But  there  are  greater  evils  than  either  sterility  or  the  premature 
termination  of  pregnancy,  to  which  patients  affected  with  fibrous 
tumors  of  the  uterus  are  liable.  The  annals  of  medicine  are  full 
of  cases  illustrating  the  dangerous  character  of  this  complication, 
which  may  expose  the  patient  to  one  or  all  of  three  dift'ereiit  perils. 
The  tumor  ma}^  meclianicall}'  prevent  the  passage  of  the  child 
through  the  pelvis,  and  may  thus  even  necessitate  the  performance 
of  the  CiBsarian  section.  It  may  interfere  with  the  efficient  con- 
traction of  the  uterus  after  the  expulsion  of  the  placenta,  and  thus 
expose  the  patient  to  hemorrhage  which  it  wnll  be  very  difficult  to 
control.  Or  lastly,  it  ma}'  interfere  with  the  processes  of  involution 
of  the  womb  after  delivery,  and  may  either  itself  undergo  a  morbid 
softening  and  disintegration,  or  may  be  the  occasion,  either  in  con- 
nection with  inflammation  of  its  own  substance  and  of  that  of  the 
womb,  or  independently  of  it,  of  peritonitis,  always  dangerous, 
too  often  fatal. 

While  I  believe  the  risk  of  any  of  these  untoward  occurrences 
complicating  labor  to  be  very  real  and  very  serious,  it  is  neverthe- 
less my  impression  that  the  danger  has  been  overstated  by  some 
writers  of  very  deserved  reputation.  There  can  be  no  doubt  but 
that  the  peril  depends  in  great  measure  on  the  intimacy  of  the 
relations  between  the  tumor  and  the  uterine  substance  ;  and  that 
those  pediculated  outgrowths  which  spring  from  the  peritoneal 
surface  of  the  uterus  are  of  no  great  moment  except  in  so  far  as  by 
their  size  and  position  they  encroach  on  the  [)elvic  cavity,  and  in- 
terfere with  the  passage  of  the  child.  I  know  four  women,  one 
of  whom  has  given  birth  to  one  child,  the  others  to  several,  from 
the  fundus  of  whose  uterus  there  springs  a  tumor  having  all  the 
characters  of  a  fibrous  outgrowth;  and  yet,  with  the  exception  of 
some  disposition  to  hemorrhage  in  two  of  the  cases  (and  that  in- 
deed by  no  means  difficult  to  restrain),  labor  and  its  consequences 
have  been  uninterru}»ted  by  any  untoward  occurrence.  Even  in 
other  instances,  the  exceptions  to  an  unfavorable  issue  are  far  too 


244  TREATMENT    OF    FIBROUS    TUMORS. 

numerous  to  warrant  us  in  admitting  the  disposition  to  disintegra- 
tion and  softening  or  suppuration  of  the  tumor  to  be  as  invariable 
an  attendant  on  advanced  pregnancy  as  some  writers  suppose. 
My  own  experience,  too,  leads  me  to  connect  the  fiital  issue,  when 
it  does  take  place,  more  with  peritoneal  inflamnmtion  than  with 
any  constant  change  in  the  substance  of  the  tumor;  while,  lastly, 
it  is  not  to  be  forgotten  that  the  softenins;  and  disinteo;ration  of 
fibrous  tumors,  when  they  occur  in  the  unimpregnated  condition, 
are  not  attended  by  any  formidable  symptoms.' 

The  bearing  of  these  facts  on  the  question  of  the  induction  *of 
premature  labor  in  pregnancy  complicated  with  fibrous  tumors  of 
the  uterus,  must  be  reserved  till  after  I  have  said  what  little  there 
may  be  to  tell  you  with  reference  to  the  general  treatment  of  the 
disease. 


LECTURE    XVII. 

UTEKIXE  TUMOKS  AND  OUTGROWTHS. 

Fibrous  Tumors.  Treatment.  Precautionary  measures  to  retard  their  growth  ; 
management  of  menstrual  periods,  and  palliative  treatment.  Alleged  specitics  : 
iodine,  bromine,  the  waters  of  Kreuznach.  Surgical  proceedings;  great  hazard 
attending  them.  Sources  of  danger,  and  management  of  pregnancy  and  labor 
complicated  with  fibrous  tumors. 

We  now  come,  last  of  all,  to  the  consideration  of  the  treatment 
of  fibrous  tumors  of  the  uterus.  The  treatment,  indeed,  of  an  ir- 
remediable disease  may  seem  to  require  but  brief  notice,  and  to 
present  but  slender  interest  to  the  student  of  medicine.  But  in 
fact  it  is  not  so.  There  are  as  large  opportunities  for  skill  in  pal- 
liating the  irremediable  ill,  as  in  curing  the  sickness  which  gives 
the  widest  scope  for  the  healing  art  to  show  itself  most  sovereign; 
and  there  are  occasions,  too,  far  more  numerous,  for  the  exercise 
of  all  those  sweet  charities  of  life  which  render  our  profession  in 
its  right  exercise  so  unalloyed  a  blessing  to  mankind.  Hereafter 
I  shall  have  to  plead  the  same  reasons  for  begging  your  most  heed- 
ful attention  to  the  management  of  cancer,  and  of  other  ailments 
more  hopeless,  more  constantly,  more  quickly  fatal  than  that  which 
we  are  now  studying.  I  urge  them  on  you  now,  however,  because 
there  is  a  not  unnatural  disposition  on  the  part  of  the  student  and 
the  young  practitioner  to  fix  their  attention  on  the  great  diseases 
which  admit  of  great  remedies,  and  to  pass  almost  unnoticed  the 
slow,  wearing  ailments,  in  which  each  day's  suffering  is  like  that 

1  With  reference  to  this  subject  and  the  practical  questions  connected  with  it, 
the  reader  may  consult  Puchelt,  De  iumorlhiis  in  pelvi  parinm  impediejitibny:,  8vo., 
HeidelbergfB,  1840,  cap.  i,  ii,  v,  pp.  58,  66,  104;  Ashwell,  Guy's  Huspital  Reports, 
vol.  i,  j>.  300  ;  Lever,  ibid.  vol.  vii,  pp.  98-103  ;  and  some  remarks  by  Dr.  Simpson 
which  first  appeared  in  the  Edhibiin/h  Monthly  Journal,  August,  1817,  and  are  re- 
published at  p.  833  of  vol.  i,  of  his  collected  Obstetric  Works,  8vo.,  Edinburgh,  1855. 


TREATMENT    OF    FIBROUS    TUMORS.  245 

of  the  day  before  ;  witli  no  prospect  indeed  of  return  to  liealth,  but 
with  a  decline  so  tardy,  marked  by  so  few  events,  that  the  shadow 
on  the  dial  seems  scarcely  to  go  down  at  alh 

Fortunately,  in  the  present  case,  the  disease  often  has  pauses  in 
its  course,  which,  though  uncertain  alike  in  their  occurrence  and 
their  duration,  are  yet  frequent  enough  to  lend  a  little  brightness 
to  the  patient's  prospects.  These,  too,  are  still  further  clieered 
by  the  rare  accident  of  a  perfect  recovery  being  now  and  then 
brought  al)Out  by  nature's  hands ;  wliile  concerning  it  we  can  fore- 
tell so  little,  that  every  patient  may  witli  almost  equal  reason  hope 
that  she  herself  will  prove  the  happy  exception  to  the  general  rule. 

We  have  already  seen  enough  of  the  conditions  that  favor  the 
development  and  growth  of  fi])rous  tumors,  to  be  able  to  infer  the 
nature  of  those  precautions  by  which  their  increase  may  be  re- 
tarded. We  find  their  growth  to  be  more  rapid,  and  their  symp- 
toms generally  to  be  more  formidable,  during  the  years  of  sexual 
activity,  than  after  the  time  when  those  functions  have  ceased ; 
while  pregnancy  and  its  consequences  are  not  only  attended  by 
certain  positive  dangers,  but  appear  to  be  accompanied  by  a  greatly 
accelerated  rate  of  increase  of  the  disease.  Hence  it  may  be  re- 
garded as  a  fortunate  circumstance  when  the  symptoms  of  this 
affection  come  on  comparatively  late  in  life,  and  we  then  venture 
to  hold  out  to  our  patient  the  expectation  of  amendment  taking 
place  when  menstruation  ceases.  Hence,  too,  a  more  encouraging 
prognosis  may  usually  be  expressed  in  the  case  of  an  unmarried 
woman,  or  of  a  widow,  than  of  one  who  is  still  cohabiting  with 
her  husband.  Apart,  indeed,,  from  the  occurrence  of  pregnancy, 
there  can  be  no  doubt  but  that  mere  sexual  intercourse  is  injurious 
to  patients  with  fibrous  tumor,  and  that  the  congestion  of  the 
uterus  and  pelvic  viscera,  and  the  increased  vitality  of  the  sexual 
organs  which  the  act  induces,  favor  its  increase.  If  then  your 
patient  be  a  married  woman,  it  is  your  duty  to  acquaint  her  with 
this  fact ;  it  is  not  generally  your  duty  to  do  more ;  for  often  there 
are  complicated  questions  iDoth  moral  and  physical  involved,  which 
3'ou  must  not  ignore,  but  into  which,  unasked,  you  have  no  right 
to  intrude. 

But  while  you  must  to  a  great  extent  leave  this  matter  to  be 
settled  by  your  patient,  there  are  some  other  points  concerning 
which  your  advice  cannot  be  out  of  place.  Independent  of  the 
risks  of  hemorrhage  which  attend  it,  the  menstrual  period  is 
always  unfavorable  to  this  class  of  patients,  and  the  more  quietly 
you  can  succeed  in  conducting  them  through  it  the  better.  Ab- 
solute rest  through  the  whole  of  each  period  is  of  great  importance; 
while,  if  much  hemorrhage  or  severe  pain  accompanies  it,  the  pa- 
tient should  remain  in  her  bed  for  the  first  forty-eight  hours,  and 
should  not  move  further  than  to  her  sofa  during  the  whole  of  its 
continuance.  If  it  sets  in  with  severe  pain,  associated,  as  is  usually 
the  case,  with  abdominal  tenderness,  a  few  leeches  over  the  hypo- 
gastrium,  or  the  tender  part  of  the  tumor  as  felt  through  the  ab- 
domen, will  often  be  of  service,  but  the  caution  which  I  have 


246  TREATMENT    OF    FIBROUS    TUMORS: 

already  given  as  to  the  inexpediency  of  leeching  the  uterus  just 
before  the  commencement  of  a  menstrual  period,  holds  good  in 
this  case.  Both  the  pain  and  the  hemorrhage  are  often  nmch 
lessened,  not  only  by  keeping  the  bowels  acting  with  regularity 
at  all  times,  but  also  by  giving  an  aperient  just  before  the  dis- 
charge commences.  If  menstruation  should  be  very  excessive, 
the  case  must  be  treated  just  like  any  other  case  of  menorrhagia, 
and  in  anticipation  of  profuse  loss  of  blood,  astringents  may  be 
employed  from  the  very  first  day  of  the  discharge  appearing,  Not 
infrequently  there  is  a  disposition  to  intercurrent  hemorrhage  be- 
tween the  periods,  which  may  in  man}'  instances  be  warded  oif 
by  complete  rest  at  the  time,  by  the  avoidance  of  all  stimulants, 
by  salines  and  sedatives,  such  as  the  citrate  of  potash  with  tincture 
of  henbane,  and  by  the  a[)plication  of  a  few  leeches  to  the  abdomen, 
if  the  tlireatcnings  of  loss  of  blood  are  accompanied  with  much 
pain.  I  do  not  think  that  in  cases  of  fibrous  tumor  of  the  uterus 
very  much  is  gained  by  the  application  of  the  leeches  directly  to 
^the  w'omb  itself,  though  in  simple  hypertrophy  of  the  organ  that 
constitutes  our  most  efficient  mode  of  treatment.  Sometimes, 
however,  when  menstruation  is  scanty,  and,  as  is  then  generally 
the  case,  painful ;  or  when  there  is  considerable  uterine  tender- 
ness, and  a  \niffy  or  indurated  condition  of  the  cervix,  much  is 
obtained  by  this  measure.  I  believe,  however,  that  then  it  is  the 
general  state  of  the  uterus,  rather  than  the  tumor  of  the  organ, 
which  is  benefited.  Much  standing,  much  exertion,  and  especially 
much  walking,  are  all  objectionable,  for  all  tend  to  produce  and 
to  keep  up  a  congested  state  of  the  pelvic  viscera.  If  these,  how- 
ever, be  interdicted,  and  the  patient  be  thereby  condemned  to  a 
sedentary  life,  it  is  obvious  that  to  maintain  her  health  she  must 
adopt  a  mild,  unstimulating  diet,  that  she  must  live  more  sim[»ly, 
even  more  abstemiously,  than  before.  On  the  degree  to  which 
you  can  command  your  patient's  confidence,  and  can  induce  her 
to  adopt  this  somewhat  self-denying  kind  of  life,  and  on  the  extent 
to  which  she  has  fortitude  to  persevere  in  it,  month  after  month, 
even  year  after  year,  will  depend  the  measure  of  her  health,  her 
comfort,  and  her  powers  of  usefulness. 

It  would  profit  but  little  to  repeat  all  that  lias  been  said  before 
when  treating  of  dysmenorrhoea  and  of  excessive  menstruation  ; 
for  the  rules  then  given  and  the  remedies  then  suggested  api)ly 
equally  to  the  mitigation  of  pain  or  the  suppression  of  bleeding 
when  dependent  on  fibrous  tumor.  It  may  not,  however,  be  super- 
fluous to  add,  that  the  steady  observance  of  the  hygienic  rules  which 
I  have  laid  down  is  of  more  importance  than  the  mere  use  of  medi- 
cines for  the  permanent  mitigation  of  either  of  these  symptoms. 

But  it  may  be  asked  whether  there  is  no  remedy  that  exerts  a 
specific  influence  on  the  growth  of  these  tumors, — none  by  which 
we  can  obtain  their  absorption,  or  at  least  feel  sure  of  putting  a 
stop  to  their  growth  ?  I  very  much  fear  that  no  such  remedy 
exists,  or  at  least  has  been  at  present  discovered.  Mercurial  prep- 
arations most  certainly  have  no  such  influence ;  and  the  alleged 


USE    OF    IODINE.  247 

powers  of  iodine  seem  to  have  been  very  miicli  overrated,  for  in  a 
very  large  proportion  of  the  instances  in  which  it  has  been  perse- 
veringly  employed,  no  effect  whatever  has  appeared  to  follow  its 
administration.  The  disintegration  of  the  tumors,  and  their  ex- 
pulsion, have  never,  in  my  experience,  succeeded  the  continued 
use  of  preparations  of  iodine,  but  have  taken  place  unexpectedly, 
and  independent  of  any  assignable  cause.  Still  it  is  possible  that 
the  rapid  increase  of  these  growths  may  be  sometimes  restrained 
by  this  agent,  and  I  therefore  employ  it  as  our  best,  though  but  an 
uncertain  remedy,  and  with  a  yearly  lessening  faith  in  its  efficacy. 
To  gain  an3-tlnng  by  it,  indeed,  it  is  essential  that  its  use  should 
be  continued  for  many  months ;  and,  in  order  to  this,  the  patient 
must  be  brought  very  gradually  under  its  influence,  since  large  or 
frequently  repeated  doses  often  disorder  the  digestion,  occasion 
slee})lessness,  or  produce  a  febrile  condition,  which  compels  the 
discontinuance  of  the  medicine.  I  seldom  give  more  than  one 
grain  of  the  iodide  of  potass  with  twenty  minims  of  the  syrup  of 
iodide  of  iron,  twice  a  day ;  and  though  in  addition  I  generally 
recommend  the  inunction  of  an  iodine  ointment  over  the  tumor, 
yet  this  is  rather  as  an  additional  means  of  impregnating  the 
system  with  iodine  than  on  account  of  any  marked  local  influence 
which  its  employment  in  this  manner  has  seemed  to  me  to  exert. 
The  introduction  into  the  vagina  of  balls  of  iodine  ointment, 
for  the  sake  of  the  supposed  local  action  of  the  remedy  on  the 
tumor,  does  not  appear  to  me  to  have  evidence  in  its  favor  sufficient 
to  counterbalance  the  obvious  disadvantages  attendant  on  constant 
local  medication  of  the  womb,  and  the  daily  introduction  of  irri- 
tants into  the  vagina.  The  same  kind  of  objection,  with  the 
additional  drawbacks  attendant  on  the  proved  in efiicacy  of  mercu- 
rials, attaches  to  the  local  use  of  the  unguentum  hydrargyri,  and  its 
injection,  as  has  been  recommended,  into  the  cavity  of  the  Avomb. 
The  bromide  of  potassium  has  been  spoken  of  as  of  sujierior 
efficacy  to  the  salts  of  iodine.  I  cannot  say  whether  it  de.-erves 
this  character  or  not ;  but  it  certainly  has  the  advantage  of  being 
better  tolerated,  and  for  a  longer  time,  by  the  patient.  It  must 
also  be  remembered  that  the  waters  of  Kreuznach'  in  Germany, 

1  Dr.  Siitro,  in  liis  work  on  the  German  Mineral  Waters,  London,  1851,  gives  at 
page  2uG  the  f(jllowing  result  of  an  analysis  by  Professor  Lijwig  of  Zurich,  of  the 
contents  of  sixteen  ounces  of  the  water  : 

72.88  chloride  of  sodium. 
13.38  "  calcium. 

4.07  "  magnesium. 

0.62  "  potassium. 

0.()1  "  lithium. 

0.27  bromide  of  magnesium. 

0.03  iodide 

1.09  carbonate  of  lime. 

0.01  '<  baryta. 

0.10  magnesia. 

0.15  oxide  of  iron. 

0.02  pho.sphate  of  alumina. 

0.12  silica. 

04.02 


248  TREATMENT    OF    FIBROUS    TUMORS: 

which  have  acquired  considerable  reputation  for  the  special  in- 
fluence which  they  are  supposed  to  exert  over  enlaro;ements  and 
fibrous  tumors  of  the  uterus,  contain  salts  of  bromine  in  much 
larger  quantity  than  those  of  iodine.  I  am  much  at  a  loss,  how- 
ever, as  to  how  far  the  alleged  influence  of  these  waters  on  fibrous 
tumors  is  a  real  one,  and  must  confess  that  in  no  instance  have  I 
seen  any  marked  diminution  of  a  tumor  result  from  their  use,  still 
less  have  I  known  a  tumor  become  absorbed  or  disappear.  The 
waters  are  no  doubt  possessed  of  great  potency,  and  in  many 
scrofulous  and  secondary  syphilitic  aft'ectious  prove  of  much  service. 
The  mode  of  their  employment,  too,  is  very  energetic,  so  tliat 
failure  cannot  be  attributed,  as  when  the  waters  are  used  in  this 
country,  to  the  imperfection  or  insufiicienc}^  of  their  application. 
For  six  or  seven  weeks  the  patient  spends  three-quarters  of  an 
hour  daily  in  a  bath,  the  strength  of  which  has  been  increased  by 
the  gradual  addition  of  from  twenty-four  to  thirty  pints  of  the 
mother  lye,  or  liquor  which  remains  after  evaporation  of  the  water, 
to  four  hundred  pints  of  the  water.  Besides  this,  twice  a  day  for 
an  hour  together,  warm  fomentations  of  the  mother  lye  are  ap- 
plied to  the  abdomen,  and  these  fomentations  are  increased  in 
strength  until  they  produce  a  burning  sensation,  and  an  eruption 
of  pimples  on  the  surface.  The  patient,  in  addition,  takes  the 
waters  internally,  and  employs  an  enema  of  two  ounces  of  the 
water,  with  twenty  to  thirty  minims  of  the  mother  lye,  every  day 
after  the  bowels  have  acted.  This  treatment  is  continued  until 
constitutional  symptoms,  indicative  of  what  is  regarded  as  satura- 
tion of  the  system  with  the  remedy,  are  produced ;  and  then,  after 
a  pause  of  three  or  four  weeks,  a  second  similar  course  of  four  or 
six  weeks  is  undergone,  and  this  plan  is  repeated  in  many  instances 
for  two  or  three  successive  summers.^ 

If  to  this  energetic  treatment  there  be  superadded  the  observance 
of  all  those  subsidiary  measures,  often  too  hard  to  enforce  in  other 
circumstances,  but  which  seldom  fail  to  be  attended  to  when  a 
patient  leaves  her  home  and  places  herself  for  some  months  under 
the  care,  not  of  an  ordinary  practitioner,  but  of  one  who  seems  to 
preside  as  a  sort  of  genius  of  the  place  over  the  wonder-working 
spring,  we  certainly  have  all  those  conditions  assembled  from 
which  most  striking  results  might  be  anticipated.  My  own  con- 
clusions, however,  are  fully  borne  out  by  the  greater  experience  of 
Scanzoni,^  who  says  that  he  "does  not  believe  that  by  these  means 
any  important  diminution  of  a  real  fibroid  tumor  has  ever  been 
effected."  It  seems,  too,  from  the  statement  of  Dr.  Prieger  himself, 
a  gentleman  who  first  brought  the  waters  of  Kreuznach  into  notice, 
and  who  for  many  years  practised  there  with  well-merited  reputa- 
tion, that  by  far  the  greater  proportion  of  cures  occurred  in  his 

1  For  this  account  of  the  plan  pursued  at  Kreuznach  I  am  indebted  to  a  letter 
from  Dr.  Engelmann,  who  has  practised  there  for  many  years,  and  has  written  a 
little  book  on  the  use  of  the  waters  in  secondary  syphilitic  atiections, —  The  Baths 
of  Ki-euznach,  8vo.,  Frankfort,  1852. 

2  Op.  cit,  p.  237. 


USE    OF    KREUZNACII    WATERS.  249 

experience  in  cases  of  simple  hypertrophy  of  the  uterus,  and  not 
of  fibrous  tumors  of  the  or2:an. 

My  own  observation  confirms  Dr.  Prieger's  statement.  I  have 
seen  simple  enlargements  of  the  uterus  consequent  on  chronic 
inflammation  of  the  organ,  or  a  deficient  involution  after  delivery 
or  miscarriage,  much  reduced  in  bulk;  and  I  have  also  seen  the 
womb  in  whose  substance  fibrous  tumors  were  imbedded  grow 
smaller,  not  from  reduction  of  the  tumor,  but  from  lessening  of 
the  hypertrophy  of  its  tissue,  to  which  the  tumor  had  given  rise. 
With  this  improvement,  too,  in  the  local  condition,  there  has 
been  a  lessening  of  the  discomforts  from  which  the  patient  pre- 
viously suffered.  I  do  not  know,  however,  that  I  have  seen  this 
relief,  in  cases  of  fibrous  tumors,  persist  for  long  after  the  patient's 
return  home,  on  her  attempt  to  resume  her  previous  mode  of  life; 
nor  have  I  found  it  to  be  more  complete  or  more  lasting  than  I 
have  seen  follow  in  other  instances  from  obedience  to  simple  rules 
deduced  from  general  principles  of  treatment.  Still,  when  our 
remedies  are  so  few,  we  cannot  well  afltbrd  to  dispense  with  any, 
even  though  their  virtues  may  he  questionable;  and  I  often  sanc- 
tion, or  even  suggest  a  visit  to  Kreuznach,  though  accompanying 
it  with  a  liint  that  relief  of  discomfort,  rather  than  absolute  cure, 
is  all  that  I  can  promise  from  the  experiment. 

I  should  also  say  that  of  late  years  the  Kreuznach  salt  and  the 
mother  lye  have  been  imported  into  this  country;  and  patients 
anxious  to  make  trial  of  their  virtues  can  obtain  them  from  most  of 
the  principal  chemists  in  London.  They  are  employed  either  in 
liip-baths,  or  in  the  form  of  epithems  worn  over  the  lower  part  of 
the  abdomen,  and  I  have  known  patients  obtain  relief  from  both 
of  these  proceedings.  I  doubt,  however,  whether  the  latter  does 
more  than  act  as  a  moderate  counter-irritant,  and  whether  the 
comfort  afforded  by  the  former  is  not  due  as  much  to  the  soothing 
influence  of  the  warm  water  as  to  the  medicinal  action  of  the  salt 
which  it  contains.^ 

If  medicine,  however,  is  so  slow,  and  confessedly  so  uncertain 
in  its  action  upon  these  growths,  are  they,  you  may  inquire, 
equally  beyond  the  reach  of  surgical  interference?  Such  of  them 
as  s[)ring  from  a  distinct  pedicle,  and  hang  down  into  or  beyond 
the  uterine  cavity,  admit  of  removal  either  by  the  knife  or  the 
ligature;  and  concerning  these  fibrous  polypi  I  shall  have  some- 
thing to  say  presently.  The  non-pediculated  growths,  with  tlie 
study  of  which  we  are  now  occupied,  and  those  pedunculated 
tumors  that  spring  from  the  outer  surface  of  the  uterus,  arc  almost 
or  altogether  beyond  our  reach.  A  few  cases  are  on  record  whore 
the  abdomen  has  been  laid  open,  and  the  extirpation  of  a  fibrous 
tumor  from  the  outer  surface  of  the  uterus  has  been  attenqited, 
and  even  actually  accomplished.      In   most  of  these  cases  the 

'  ()no  pintof  tlin  mothor  lyo  and  one  jioiintl  of  common  salt  in  an  ordinary  lii]>- 
batli  ofSii"  is  a  .eviffii'icntly  close  imitation  of  tho  baths  of  the  mineral  s)>rin^  itself, 
dift'eiin<^  from  it  chiefly  in  beini:!;  stronger  than  the  baths  are  at  Krouznach,  in 
which  the  whole  body  is  immersed. 


250  TREATMENT    OF    FIBROUS    TUMORS: 

operation  was  undertaken  with  the  impression  that  the  tumor  was 
ovarian,  and  in  all  instances  but  one,  which  is  reported  by  an 
American  surgeon,  Dr.  Atlee,  its  completion  was  followed  by  the 
patient's  death.  It  is  a  proceeding  to  be  altogether  deprecated, 
difficult  to  accomplish,  almost  certainly  fatal  if  concluded,  sur- 
rounded by  dangers  which  wisdom  cannot  foresee,  nor  skill  avert. 
It  would  perhaps  not  be  right  to  pass  quite  so  sweeping  a  con- 
demnation on  another  operation  which,  since  its  first  performance 
by  M.  Amussat,  has  had  several  imitators,  and  which  consists  in 
the  enucleation  of  fibrous  tumors  of  the  uterine  walls  by  an  incis- 
ion made  through  the  os  uteri,  or  the  lower  segment  of  the  womb. 
No  one  can  have  noticed  the  extremely  loose  connection  between 
the  uterus  and  fibrous  tumors  imbedded  in  its  substance,  without 
the  feasibility  of  an  operation  for  their  removal  occurring  to  his 
mind,  and  it  was  suggested,  on  theoretical  grounds,  by  M.  Velpeau, 
some  years  before  the  idea  was  put  in  ju-actice  in  1840  by  M. 
Anmssat.  The  results  of  it,  however,  are  by  no  means  encourag- 
ing, so  long  as  we  limit  our  inquiry  to  cases  of  enucleation  of  inter- 
stitial fibrous  tumor  of  the  body  of  the  uterus,  for  twenty-eight 
operations  yield  fourteen  deaths  to  fourteen  recoveries,  while  in 
four  of  the  latter  tlie  operation  was  incomplete,  and  a  portion  of 
the  tumor  was  left  behind.^     If  now  to  the  published  mortality 

1  The  followinc:  references  include  all  the  cases  with  which  I  am  acquainted  that 
strictly  belong  to  this  category: 

STJCCKSSFUL   CASES. 

Amussat,  2  cases,  reported  in  full  in  Exnrninnieur  MSdicale,  Feb.,  1843. 

Maisonneuve,  2      "      Bulletin  de  I' Acad,    de   Med.,   xiv,    722;    and    Gazette  des 

Bopitait.v,  Dec.  (i,  1849. 
Grimsd.ale,        1      "      Liverpool  Medico-Chirurqical  Journal,  Jan.,  1857,  p.  54. 
Teale,  1      "      Medical  Times,  March  22,  18-36,  p.  28-3. 

Atlee,  7      "       Timnsaciiona  of  American  Medical  Association,  \o\.y\,\>.  ^io^. 

Davis,  1      "       Transactions  of  the  Obstetrical  Society,  vol.  ii,  18G1,  p.  17. 

— 14  cases. 

FATAL   CASES. 

Boyer,  1  case,  Revue  Medicate,  March,  1845;  death  in  6  days. 

Berard,  2      "     Bull,  de  la  Societe  Anatomique,  1842,  j).  82  ;  death  in  5  weeks  ; 

in  his  other  case  mentioned  by  Jarjavay,  death  took  place 
in  2  days. 

Maisonneuve,  1  "  Bulletin  de  la  Societe  de  Chirurgie,  vol.  i,  pp.  458,  474.  M. 
Maisonneuve  does  not  himself  mention  the  death  of  the 
patient,  but  the  fact  is  mentioned  by  .Jarjavay,  who  states 
that  death  took  place  at  the  end  of  a  month.  See  the 
translation  of  his  thesis,  "  Des  Operations  aux  Corps 
Fibreux  de  I'Uterus,"  in  vol.  vii,  of  the  Analekten  fur 
Frauenkranliheiten,  p.  426. 

Chiari,  1     "     Klinik  der  Geburtshiilfe,  &c..  p.  408;  died  in  36  days. 

Baker  Brown,  2  "  Medical  Times,  July  2-5,  1857;  death  of  one  in  30  hours,  of 
the  other  in  13  days. 

Atlee,  5     "     Loc.  cit.     The  date  of  death  was  1  month,  11  daj's,  5  days, 

7  weeks,  and  20  days  respectively,  after  the  first  operation 
was  attempted. 

Simpson,  1     "     Ed.  Monthly  Journal,  March,  1848,  and  republished  in  the 

Obstetric  Memoirs,  p.  118;  died  in  6  days. 

Self,  1     " 

— 14  cases. 

The  temptation  to  suppress  due  mention  of  cases  having  an  unfortunate  issue 


THEIR    ENUCLEATION.  251 

we  make  some  atldition, — and  I  fear  it  ought  to  be  a  very  large 
one, — for  suppressed,  or  at  least  for  non-reported  cases,  we  arrive 
at  a  result  wliicli  compels  us  to  class  the  operation  among  the 
most  hazardous  in  surgery.  These  risks,  too,  be  it  observed,  are 
incurred  not  in  the  case  of  a  disease  surely  and  rapidly  destroying 
life,  but  of  one  that  runs  a  slow  course,  that  often  comes  to  a 
standstill  of  its  own  accord,  and  that  almost  always  atfords  a  pros- 
pect of  months  or  years  of  valetudinarianism  indeed,  but  still  of 
life,  wdiich  the  operation  may  cut  short  in  a  few  days.  Success, 
on  the  other  hand,  by  no  means  necessarily  frees  the  patient  from 
her  ills,  for  fibrous  tumors  are  but  seldom  solitary,  and  the  removal 
of  one  may  but  serve  to  bring  to  light  the  existence  of  another 
beyond  tlie  reach  of  surgical  interference. 

In  the  performance  of  the  operation  itself,  the  main  difliculties 
seem  to  arise  from  the  size  of  the  tumor,  the  inadequate  si)ace 
afibrded  by  the  opening  of  the  os  uteri,  which  it  has  generally  been 
necessary  to  incise  or  to  dilate  forcibly,  and  from  a  thinness  of  the 
uterine  parietcs,  so  extreme  as  to  necessitate  the  most  cautious 
manipulation,  lest  the  peritoneal  cavity  should  be  opened  in  the 
endeavor  to  extract  the  tumor.  It  must,  indeed,  be  imposrsible 
for  any  one  to  read  the  particulars  of  operations  such  as  those  of 
Amussat  and  Boyer,  where  the  patient  was  more  than  two  hours 
under  the  hands  of  the  surgeon  ;  or  of  that  of  Maisonneuve,  in 
which  the  hemorrhage  that  immediately  followed  it  was  very 
alarming,  without  feeling  much  hesitation  as  to  the  propriety  of 
ex})Osiiig  a  person  to  so  great  a  risk  for  advantages  so  uncertain. 
It  is  not^  however,  the  loss  of  blood,  for  that  is  not  in  general  con- 
siderable, nor  the  immediate  eifect  of  the  shock,  which  is  most  to 
be  apprehended,  for  no  patient  appears  to  have  died  from  hemor- 
rhage, and  only  two  from  the  direct  shock,  and  one  of  these  paticjits 
had  already  been  exhausted  by  frequent  operations.  Peritonitis, 
phlebitis,  and  pj-iemia,  the  consequences  of  violence  done  to  the 
uterus  of  women  exhausted  by  large  and  frequently  repeated  flood- 
ings,  are  dangers  from  which  but  few  have  altogether  escai)ed ; 
under  which  I  fear  that  correct  statistics  would  show  that  most 
have  succumbed. 

scorns  almost  insurmonntublo,  while  it  vitiates  all  the  conclusions  whicfi  wc  may 
attempt  to  draw  from  the  statistics  of  those  adventurous  operations.  Thus,  in  the 
discussion  that  arose  at  the  iSociet^  de  Chirurgie,  on  Dec.  5,  1849,  with  reference  to 
M.  ]\Iaisonneuve''s  third  and  fatal  case,  tliat  j^entleman  himself  mentioned  having 
seen  a  "  i,'ood  number"  of  unsuccessful  attempts  at  enucleation  of  tilimns  tuinors, 
all  of  whicii  had  a  fatal  issue;  while  M.  Huuuier  relates  an  instance  where  death 
took  place  tw<j  days  after  another  unsuccessful  operation  at  wiiieh  he  himself  as- 
sisted. Our  tables,  however,  bear  no  record  of  these  failures  and  deaths,  any  more 
tlian  of  two  other  fatal  cases  of  Dr.  Simjison's,  makini^  three  deaths  out  of  four 
operations,  which  are  referred  to  by  Dr.  Arneth,  of  Vienna,  in  his  "  Im]»ressions 
of  a  Journey,"  published  in  the  Wiener  Znisr/irift,  viii,  3,  18")2,  and  Sc/nniilt,  vol. 
Ixxv,  ]).  823.  It  is  to  be  regretted  that  Dr.  Simjison's  Ohstetrir  Memoirs  have  had 
so  littl(!  of  his  supervision  as  to  contain  no  account  of  many  of  those  failures  in  this 
or  in  other  cases,  which  no  skill  can  ]>revent,  which  are  known  to  have  modified 
his  own  practice,  and  which  migiit  attbrd  lessons  so  well  worth  learning  to  others. 


252  TREATMENT    OF    FIBROUS    TUMORS: 

The  amount  of  difficulty  in  the  performance  of  the  operation, 
and  the  degree  of  risk  which  it  will  entail  on  the  patient,  can 
scarcely  be  estimated  beforehand;  and  of  this  it  would  not  be  easy 
to  give  an  apter  illustration  than  is  furnished  by  my  own  unsuc- 
cessful case  of  attempted  enucleation  of  a  fibrous  tumor. 

The  patient  was  thirty-nine  years  old,  the  mother  of  three  chil- 
dren. The  first  symptom  of  her  disease  ha'd  appeared  a  year  before, 
when  she  had  a  sudden  attack  of  most  profuse  hemorrhage,  which 
returning  thrice  at  intervals  of  a  fortnight,  reduced  her  to  a' state 
of  extreme  exhaustion.  The  enlarged  uterus  was  only  with  diffi- 
culty felt  by  the  hand  over  the  pubes ;  its  enlargement  was  due 
to  the  presence  of  a  tumor  as  large  as  an  orange,  imbedded  in  the 
anterior  uterine  wall,  which  had  distended  the  os  uteri  to  aljout 
the  size  of  the  top  of  a  wine-glass,  but  did  not  project  beyond  its 
margins,  the  surface  of  the  tumor  being  adherent  to  the  anterior 
uterine  lip.  The  uterine  sound  appeared  to  circumscribe  more  than 
half  of  the  growth.  The  moderate  size  of  the  tumor,  the  open  state 
of  the  OS  uteri,  and  the  circumstance  tliat  so  large  a  portion  of  the 
tumor  was  unattached,  seemed  both  to  Mr.  Paget  and  mj^self  to 
render  the  case  one  in  which,  if  hemorrhage  returned  dangerously, 
enucleation  might  be  attempted.  For  a  few  months  no  consider- 
able bleeding  took  place ;  but  then  the  hemorrhages  returned ; 
and  ten  months  after  the  patient  first  came  under  my  notice,  the 
operation  was  attempted,  the  tumor  apparently  retaining  very 
nearly  its  original  size  and  relations.  A  pair  of  hooks  were  firmly 
fixed  in  the  tumor,  and  by  their  means  the  uterus  was  drawn  down 
near  to  the  vulva.  The  anterior  uterine  lip  was  then  dissected  off 
from  it,  and  as  far  as  the  finger  could  reach  the  shelling  of  the 
tumor  out  of  its  investing  membrane  was  easily  accomplished. 
The  hand  was  partly  introduced  into  the  cavity  of  the  womb,  and 
the  detachment  of  the  tumor  posteriorly  was  accomplished ;  but 
no  efibrt  succeeded  in  reaching  high  enough  in  front  to  complete 
its  separation.  Attempts  were  made  in  vain  to  separate  the  growth 
by  traction,  or  to  invert  the  uterus  so  as  to  bring  it  within  reach 
of  the  finger,  but  in  vain ;  and  the  operation  was  left  incomplete 
after  the  enucleation  of  about  four-fifths  of  the  tumor  had  been 
accomplished.  Before  abandoning  the  attempt,  however,  incisions 
were  made  in  various  directions  into  the  substance  of  the  growth, 
in  the  hope  that  its  vitality  might  be  destroyed,  and  that  event- 
ually it  might  be  got  rid  of  in  a  state  of  disintegration. 

The  operation  lasted  about  an  hour,  very  little  blood  was  lost 
in  its  performance,  but  the  patient  suffered  much,  and  was  left  in 
a  state  of  great  depression,  which  seemed  to  require  the  liberal 
employment  of  stimulants.  As  this  condition  subsided,  the  com- 
plaints of  abdominal  pain  became  greater,  and  the  tenderness  more 
exquisite,  on  which  account  two  dozen  leeches  were  applied  on  the 
third  day  after  the  operation,  and  mercurials  were  given  which 
produced  salivation  in  five  days,  marked  relief  of  all  the  symptoms 
taking  place  about  the  same  time.     A  profuse,  fetid,  and  very 


THEIR    ENUCLEATION.  253 

acrid  discharge  came  on  soon  after  the  operation,  and  continued 
for  more  than  a  month,  causing  the  patient  much  distress  h}'  ex- 
coriating the  vulva  and  nates;  but  though  the  whole  of  the  tumor 
disappeared,  it  was  but  once  that  a  very  small  portion  of  it  was 
discovered  in  the  matter  which  flowed  from  tlie  vas-ina.  The 
operation  was  performed  on  December  21st;  by  January  5tli  the 
patient  seemed  to  be  in  a  state  of  safety;  and  before  the  end  of 
the  month  she  was  able  to  walk  about  the  ward.  On  February 
11th  she  complained  of  some  increase  of  pain  in  tlie  left  iliac 
region,  which  subsided  on  the  application  of  half  a  dozen  leeches; 
and  which  seemed  the  less  to  call  for  any  serious  anxiety,  since 
the  patient  a  few  days  before  had  menstruated  scantily,  though 
naturally.  In  the  afternoon  of  February  14th,  how'cver,  the 
patient,  who  had  been  up  and  walking  about  in  the  morning, 
was  seized  with  a  violent  rigor  and  a  return  of  pain,  which  once 
more  subsided  completely  on  the  application  of  a  few  leeches,  and 
the  administration  of  an  opiate.  On  the  20th  she  was  so  well  that 
she  was  about  to  leave  the  hospital  the  next  day;  but  at  two  o'clock 
in  the  morning  w^as  attacked  by  violent  shivering,  intense  ab- 
dominal pain,  and  those  indications  of  collapse  which  accompany 
peritonitis  from  intestinal  perforation,  and  died  at  four  o'clock  in 
the  afternoon  of  the  same  day. 

After  death,  all  the  evidences  of  recent  acute  peritonitis  Avere 
discovered,  wath  a  considerable  quantity  of  a  sero-purulent  fluid  ; 
which  in  the  pelvic  cavity  was  found  to  consist  almost  entirely  of 
pus.  This  pus  seemed  to  proceed  from  the  cellular  tissue  between 
the  uterus  and  rectum,  though  the  abscess  there  did  not  appear 
to  have  been  large.  The  matter  had  escaped  into  the  peritoneal 
cavity  through  several  small  openings  formed  by  sloughing  of  the 
serous  membrane  in  that  situation.  The  uterus  Avas  healthy ;  the 
upper  part  of  its  cavity  retained  its  ordinary  appearance,  but  a 
little  above  the  os  there  existed  a  cavity  formed  at  the  expense  of 
the  uterine  wall,  which  was  here  less  thick  than  elsewhere.  This 
cavity,  which  was  evidently  the  bed  whence  the  tumor  had  been 
removed,  measured  1]  inch  in  its  lateral  diameter,  half  an  inch 
in  dc])th,  and  the  same  in  its  antero-posterior  diameter.  It  was 
lined  by  soft,  pale  granulations,  and  no  trace  of  the  tumor  was  to 
be  seen  in  it. 

But  for  the  bursting  of  this  abscess  into  the  peritoneum  this 
case  would  have  been  numbered  among  the  successes.  The  fatal 
accident,  it  is  true,  was  one  of  very  rare  occurrence,  unlikely  to 
happen  again  on  another  occasion,  but  it  is  this  very  liability'  to 
rare  accidents  which  foresight  cannot  anticipate  nor  skill  piwent 
that  serves  to  distinguish  these  exceptional  proceedings  from  those 
operations  whose  indiciitions  can  be  clearly  detined  and  their 
dangers  accurately  estimated,  and  A\hieh  htll  within  the  more 
legitimate  domain  of  surgery. 

It  seems  to  me  worthy  of  consideration  how  far  the  mere  ineising 
fibrous  tumors,  so  as  to  destroy,  or,  at  any  rate,  greatly  to  impair 


254  TREATMENT     OF    FIBROUS    TUMORS: 

their  vitality,  might  be  substituted  for  the  more  hazardous  attempt 
at  their  entire  enucleation.  In  the  case  just  narrated,  this  might 
have  been  done  without  the  infliction  of  any  such  violence  on  the 
uterus  as  was  inseparable  from  the  attempt  at  the  complete  re- 
moval of  the  tum.or ;  and  some  instances  have  since  been  recorded, 
in  which  the  gouging  out  a  portion  from  the  centre  of  a  fibrous 
tumor  of  the  uterus  has  proved  successful.'  The  great  hazard 
attending  this,  as  well  as  all  other  operations  on  the  sexual  organs 
of  women,  is  that  of  the  supervention  of  pysemia;  and  it  must 
not  be  forgotten  that  the  previous  exhaustion  of  the  patient  by 
frequent  hemorrhages  renders  her  specially  liable  to  this  acci- 
dent. 

But  while  the  hazard  attendant  on  operations  for  the  enucleation 
of  interstitial  fibrous  tumors  of  the  uterus,  when  still  imbedded 
in  the  walls  of  the  organ,  is  so  extreme  as  to  render  them  generally 
inadmissible,  and  to  remove  them  to  thiit  class  of  exceptional  pro- 
ceedings which  the  special  condition  of  the  patient,  and  the  unusual 
dexterity  of  the  surgeon  alone  justify,  there  is  a  class  of  cases  in 
which  the  attempt  at  the  removal  of  these  growths  maybe  admis- 
sible. Such  are  those  instances,  some  ot"  which  are  recorded  by 
Lisfranc,-  where  a  small  tumor  was  imbedded  in  the  substance 
of  the  uterine  lip,  and  its  removal  could  consequently  be  efl:ected 
without  any  violence  to  the  cavity  of  the  womb.  A  case  of  this 
kind  was  recently  under  my  care  in  St.  Bartholomew's  Hospital. 
The  tumor,  which  weighed  2}  ounces,  and  which  presented  all 
the  ordinary  characters  of  a  fibrous  tumor,  was  imbedded  in  the 
posterior  lip  of  the  uterus  of  a  patient  aged  forty-seven.  An  in- 
cision was  made  by  Mr.  Paget  along  the  whole  posterior  surface 
of  the  uterine  lip,  and  was  carried  forwards  to  the  margin  of  the  os. 
The  growth  was  tlien  shelled  out  by  the  finger  with  the  greatest 
ease,  except  at  one  small  point  at  its  front  and  upper  part,  where 
it  adhered  firmly  to  the  uterine  tissue,  but  was  detached  by  a  few 
strokes  of  the  bistourj'.  No  hemorrhage  of  importance,  nor  any 
bad  symptoms,  followed  the  operation,  and  the  patient  left  the 
hospital  quite  well  in  a  fortnight. 

The  operation,  too,  is  comparatively  free  from  danger  in  those 
cases  where  the  tumor  has  approached  the  pedunculated  form, 
and  has  consequently  been  easily  reached  through  the  widel}'  open 
or  easily  divided  os  uteri,  or  perhaps  has  admitted  of  still  readier 
removal,  owing  to  its  having  passed  beyond  the  orifice  of  the 
womb,  and  come  to  lie  almost  completely  within  the  vagina.  The 
operation  here  would  seem  to  stand  on  much  the  same  footing 
with  operations  on  pedunculated  tumors  or  polypi ;  and  the  de- 
tails of  cases  such  as  those  of  Dr.  Pancoast,^  Mr.  Teale,^  Dr.  Gil- 

'  Baker  Brown,  Ohstet.  Trajisact.,  vol.  iii,  p.  67. 

2  Cliniqiie  Chirurgkale,  &c.,  vol.  ii,  pp.  172,  173,  178,  179. 

3  Boston  Med.  Journal,  Oct.  9,  1844. 

*  Med.  Times,  Aug.  20,  1853 ;  und  Ibid.  March  22,  1856. 


THEIR     ENUCLEATION.  255 

bert,'  and  M.  Langeiibcck.^  appear  to  bear  out  the  correctness  of 
a  supposition  wbicli  lias  all  tlicoretieal  probabilities  in  its  favor. 
Absolute  safety,  bowcvor,  cannot  be  claimed  even  for  tbis  simple 
operation.  I  performed  it  once  on  a  patient  wlio  bad  long  sntlered 
from  afibrons  tnmor,  whicb,  growing  somewbat  in  a  polypoid  form, 
bad  on  tbree  previous  occasions  been  partially  removed.  At  length 
spontaneous  inversion  of  tbe  uterus  took  place,  and  tbe  tnmor 
witb  tbe  inverted  womb  was  now  easily  drawn  by  a  pair  of  mid- 
wifery forceps  beyond  tbe  vulva.  Tbe  mass,  weigbing  six  ounces, 
was  readily  sbelled  out  of  tbe  uterine  tissue  by  tbe  baiid,  and 
scarcely  an}^  blood  was  lost  in  accomplisbing  this;  the  inverted 
womb  being  afterwards  readily  replaced.  Seventeen  days  after- 
wards tbe  patient  died  of  pyoemia;  a  large  coagulum,  in  which 
pus  cells  were  abundantly  present,  filled  tbe  inferior  vena  cava, 
and  there  were  purulent  deposits  in  the  lungs,  spleen,  and  left 
kidney,  though  tbe  large  uterus,  its  appendages,  and  its  veins, 
w^ere  perfectly  healthy. 

There  is  still  one  resource  left  us  in  cases  where  the  hemorrhage 
produced  by  a  fibrous  tumor  is  very  formidable  and  uncontrol- 
lable, while  the  patient's  condition  forbids  tbe  adoption  of  any 
grave  surgical  proceeding.  This  consists  in  making  free  incisions 
into  the  os  uteri,  and  great  diminution  of  the  bleeding  seems  al- 
most always  to  have  resulted  from  it,^  though  I  confess  tliat  I  do 
not  understand  the  mode  in  which  this  efiect  is  to  be  explained. 
I  once  had  recourse  to  it  with  partial  success;  but  the  patient^ 
already  much  exhausted,  sank  a  few  weeks  after  under  the  slight 

1  Boston  Med.  Journal,  vol.  xxxi,  p.  350.  For  this  last  reference,  and  also  for 
calling  my  attention  to  Dr.  Atlee's  cases,  I  am  indebted  to  some  very  interesting 
jiapers  by  Hutchinson,  in  the  Medical  Times,  July  25  to  August  15,  1857.  Four 
of  the  cases,  however,  which  he  includes  in  his  table  being  those  of  operations  on 
two  patients  with  recurrent  fibroid  tumor  of  the  uterus,  appeared  to  me  to  be  out 
of  place  there,  and  for  the  reason  assigned  in  the  text;  the  seven  cases  just  referred 
to  seemed  to  require  to  be  ranged  in  a  diiierent  category  from  that  to  which 
operations  on  interstitial  fibrous  tumors  belong.  This  division  appears  to  me  to 
convey  a  juster  impression  of  the  sources  of  danger  from  tbe  operation  tlian  one 
based  on  the  mode  of  its  performance.  In  many,  enucleation  by  the  induction  of 
gangrene  was  attempted,  only  because  primary  enucleation  had  been  attempted 
and  failed.  The  verjf  uncertainty  in  cases  of  interstitial  fibrous  tumor  as  to  which 
operation  will  be  practicable,  or  whether  both  may  not  alike  prove  impossible, 
constitutes  to  my  mind  the  great  objection  to  these  proceedings.  The' real  question 
is  ob.scured,  if  stated  so  as  to  seem  one  concerning  the  comparative  merits  of  two 
kinds  of  operations. 

■■^  Deidsche  Klinik,  1859,  p.  1^_^  Three  cases  are  related,  one  of  which  does  not 
belong  here,  since  the  operation  was  performed  as  a  matter  of  neci'ssity  during 
labor,  when  the  patient  was  already  nuich  exhausted,  and  death  was  attributable 
to  the  delay  rather  than  to  the  operation.  The  other  two  cases,  which  bad  a  suc- 
cessful issue,  illustrate  the  indications  for  the  performance  of  the  operation,  which 
M.  Langenbeck  defines  as  being  "The  youth  of  the  pat'ent,  the  dangerous  nature 
of  the  hemorrhage,  and  the  seat  of  the  tumor  in  the  substance  of  either  lip  or  of 
either  wall  of  the  cervix  uteri,  so  that  it  can  be  reached  by  the  knife,  without 
forcibly  drawing  down  the  womb."  Two  other  additional  cases  by  M.  S.iiit<-;s.m 
and  31.  Janger,  both  of  which  had  a  favorable  issue,  are  related  in  Schmidt's  Jahr- 
burJicr,  1858,  vol.  100,  p.  41. 

^  Sec  some  cases  recorded  by  Dr.  McClintock,  op.  cit.,  p.  147. 


256  MANAGEMENT    OF    LABOR 

hemorrhage  which  still  continued,  and  sj-mptoms  of  pjcemia  for  a 
few  days  preceded  her  death. 

In  conclusion,  and  before  taking  leave  of  the  subject  of  fibrous 
tumors,  a  few  remarks  must  be  made  on  the  management  of 
cases  in  which  they  occur  as  complications  of  pregnancy  or  labor. 
It  happens  occasionally,  as  in  a  case  which  some  years  since  came 
under  my  own  observation,  that  the  pelvic  cavity  is  found  at  the 
commencement  of  labor  occupied  by  a  large  and  firm  tumor,  the 
existence  of  which  had  not  been  betrayed  previously  by  any  s^mip- 
toms  whatever  of  uterine  disease.  In  some  of  these  cases  the 
Csesarean  section  has  been  performed,  but  I  am  not  acquainted 
with  any  instance  where  a  favorable  result  has  followed  the 
operation  when  rendered  necessarj'-  by  uterine  tumor.  The 
presence  of  the  growth  both  interferes  with  the  due  contraction  of 
the  womb,  and  thus  exposes  the  patient  to  great  risk  of  hemor- 
rhage, and  also,  if  this  danger  be  surmounted,  seems  to  insure  the 
supervention  of  inflammation  of  the  uterus  and  peritoneum  of  a 
kind  so  perilous,  that  in  every  recorded  instance  it  has  hitherto 
proved  fatal.  Unfortunately  the  cases  are  but  very  few  in  which 
extirpation  of  the  tumor  is  possil)le,  for,  in  comparison  with  any 
operation  by  which  the  peritoneal  cavity  is  laid  open,  that  would 
seem  to  bo  far  less  hazardous.  The  successful  removal  of  polypi 
during  lal)or,  and  the  extirpation  of  large  fibrous  tumors  of  the 
pelvic  walls,'  encourage  to  such  a  proceeding;  but  the  only  in- 
stances with  which  I  am  acquainted  of  the  actual  enucleation  of  a 
fibrous  tumor  from  the  uterus  itself  during  labor,  are  related  by 
M.  Danyau,^  AI.  Langcnbeck,^  and  Dr.  Keating.^  M.  Danyau's 
patient  Avas  thirty  years  old,  had  given  liirtli  to  three  children,  after 
^easy  labors,  and  had  reached  the  end  of  her  fourth  pregnancy, 
though  slight  hemorrhage  had  been  going  on  for  three  weeks. 
Forty  hours  after  the  escape  of  the  liquor  amnii,  a  foot  of  the 
child  was  felt  presenting,  while  the  pelvic  cavity  was  almost  com- 
pletely filled  by  a  tumor  which  seemed  to  be  formed  by  the 
thickened  posterior  lip  of  the  uterus,  and  which  did  not  leave  a 
space  of  above  three-quarters  of  an  inch  to  an  inch  and  a  quarter 
between  itself  and  the  symphysis  pubis.  The  child  having  been 
ascertained  to  be  dead,  and  no  question  therefore  arising  as  to  the 
performance  of  the  C^esarean  section,  M.  Danyau,  having  consulted 

1  A.s  in  the  remarkable  case  related  by  the  late  Professor  Burns  of  Glasgow,  in 
his  Midwifery^  eighth  edition,  8vo.,  London,  18-32,  p.  33. 

2  Gaz.  des  Hopitaux,  No.  xlii,  1851  ;  and  iSchmidt's  Jahrbucher,  vol.  Ixxi,  August, 
1851,  p.  190. 

^  Loc.  cit.,  p.  3. 

*  Americnn  Journal  of  Med.  Sciences,  May,  1858  ;  and  Schmidt,  vol.  100,  p.  40. 
I  purposely  do  not  go  into  the  consideration  of  those  cases,  of  which  several  are  on 
record,  with  varying  results,  of  the  extirpation  of  polypi  or  of  non-pediculated 
tumors  soon  after  delivery,  for  I  have  no  personal  experience  on  the  subject.  My 
leaning,  however,  would  be  to  non-interference  with  them  in  the  puerperal  state, 
unless  symptoms  urgentlj'  called  for  an  opposite  course,  since  I  should  fear  that 
the  greater  facility  of  their  removal  would  be  more  than  outweighed  by  the  greater 
risk  of  purulent  absorption  afterwards. 


WITH     UTERINE    TUMOR.  257 

Avith  Professor  Dubois,  carried  a  bistoury  on  two  fingers  of  liis  left 
hand  througli  tlie  os  uteri,  whicli  was  open  to  tlie  size  of  tlie  top 
of  a  small  wine-glass,  made  a  longitudinal  incision  through  the 
anterior  and  upper  part  of  the  tumor,  and  then  succeeded  with 
two  fingers  of  the  right  hand  in  shelling  it  out  of  the  uterus,  and 
removing  it  from  the  pelvis.  The  tumor  weighed  twenty  ounces 
seven  drachms;  its  longest  diameter  was  five  inches  and  three- 
quarters  ;  its  shape  conical,  with  the  apex  downwards.  The  ex- 
traction of  the  child  was  easily  accomplished  after  the  removal 
of  the  tumor,  and  the  patient  recovered  without  any  bad  symp- 
toms, though  a  considerable  quantity  of  venous  blood  escaped  at 
the  commencement  of  the  o[)eration,  when  the  tumor  was  first  cut 
into.  The  patients  of  M.  Langenbeck  and  of  Dr.  Keating  were 
less  fortunate.  The  former,  exhausted  by  the  previous  long  dura- 
tion of  labor  pains,  died  within  twenty-four  hours,  while  the  latter 
was  attacked  by  puerperal  phlebitis,  which  proved  fatal  on  the 
eighth  day. 

In  all  cases,  however,  where  it  is  practicable,  operations  on  the 
parturient  uterus  are  to  be  avoided,  and  the  first  thing  to  ascertain 
with  reference  to  any  tumor  is  whether  it  admits  of  being  moved 
out  of  the  Jiclvic  cavity,  since,  if  that  can  be  done,  it  is  obviously 
attended  with  the  least  possible  hazard.  In  my  own  case  it  was 
readily  accomplished;  and  there  can  be  little  doubt  but  that  the 
same  proceeding  would  have  been  successful  in  the  case  well 
described  and  delineated  by  Dr.  Etlinger,^  in  which  Professor 
Kilian  of  Bonn  performed  the  Caesarean  section  on  a  patient  whose 
pelvis  was  occupied  by  a  fibrous  tumor  that  grew  by  a  rather 
broad  peduncle  from  the  posterior  surface  of  the  womb.  This 
person  died  forty-eight  hours  after  the  operation,  from  the  effects^ 
of  the  hemorrhage  which  attended  it.  My  patient  survived  till 
the  sixth  day,  and  I  cannot  but  attribute  her  death  to  an  attempt 
which  was  made  (injudiciously  on  ni}'  part)  to  puncture  the  tumor 
before  trying  to  awry  it  above  the  pelvic  brim.  There  waa  no 
general  peritonitis,  but  the  wound  in  the  tumor  was  gaping  widely ; 
the  tissue  about  it  was  of  a  black  color,  and  discoloration  exten- 
ded thence  inwards  towards  the  centre  of  the  tumor.  The  dark 
portion  of  the  tumor  was  softened,  but  the  rest  of  it  was  of  a  vivid 
red  color,  and  neither  it  nor  the  other  tumor,  which  was  about 
the  same  size,  namely,  that  of  the  head  of  a  foetus  at  seven  months, 
presented  any  trace  of  that  general  softening  and  disintegration 
which  have  been  alleged  to  occur  in  these  growths  after  delivery. 
The  intestines  in  the  left  iliac  fossa  were  nuitted  together  by  ivcent 
l3'mj)h,  and  about  four  inches  of  thon,  just  where  they  lay  in  c(Ui- 
tactwith  the  i)unctured  tumor,  was  much  congested,  quite  rotten, 
and  their  ])osterior  part  was  converted  into  a  large  greenish-black 
slough.  This  slough  corres[)onded  to  a  large  slough  on  the  outer 
and  upper  part  of  the  punctured  tumor.     The  other  tumor  was 

1  Etliiiger,  Ohservatiojies  Ohsietricicp,  4to.,  Bonniv,  1854,  soo  pp.  50-50,  and  plates 

i  and  ii. 

17 


258       MANAGEMENT    OF    LABOR    WITH    UTERINE    TUMORS. 

of  a  rose  tint ;  the  uterus,  wliicli  presented  some  half-dozen  small 
tumors  about  the  size  of  peas  on  its  surface,  was,  in  other  respects, 
perfectly  healthy.  It  seemed,  in  short,  as  if  the  puncture  of  the 
tumor  had  been  the  point  of  departure  whence  all  the  subsequent 
mischief  proceeded.' 

In  all  instances,  then,  the  endeavor  to  carry  the  tumor  out  of 
reach  should  precede  any  attempt  at  reducing  its  bulk  by  puncture. 
In  the  event,  however,  of  the  former  failing,  the  apparent  solidity 
of  the  growth  must  not  be  taken  as  warrant  sufficient  for  dispens- 
ing witli  the  trocar,  for  a  cyst,  if  very  tense,  either  from  the  ac- 
cumulation of  fluid  within,  or  from  any  very  great  pressure  upon 
it  from  without,  will  often  yield,  even  to  the  well-practised  finger, 
scarcely  any  sensation  by  which  the  nature  of  its  contents  can  be 
suspected 

Lastly,  I  am  disposed  to  think  that  in  almost  all  of  these  cases 
it  will  be  preferable  to  turn  the  child  rather  than  to  make  any  at- 
tempt at  extracting  it  with  the  forceps;  and  even  if  the  want  of 
space  be  very  great  indeed,  craniotomy,  followed  by  turning  (and 
little  though  it  may  be  used  in  this  country,  I  cannot  refrain  from 
adding  the  use  of  the  cephalvtribe  to  break  up  the  base  ,of  the 
skull),  will,  I  doubt  not,  enable  us  to  carry  to  a  safe  conclusion  a 
case  which  at  first  appeared  to  ofifer  no  alternative  but  the  per- 
formance of  the  Ciiesarean  section. 

At  the  close  of  the  last  Lecture,  I  stated  my  dissent  from  the 
opinion  that  there  is  a  constant,  or  at  least  a  general  tendenc}'  on 
the  part  of  these  tumors  to  pass  into  a  state  of  softening,  or  disin- 
tegration during  pregnancy.  I  do  not  therefore  conceive  that  the 
induction  of  premature  labor,  and  still  more  of  abortion,  simply 
because  a  fibrous  tumor  is  connected  with  the  uterus,  is  either 
necessary  or  justifiable.  The  presence  of  a  fibrous  tumor  so  en- 
croaching on  the  pelvic  cavity  as  to  render  labor  difficult  or  dan- 
gerous, is  of  course  an  indication  for  the  operation  ;  so  also  may 
perhaps  be  the  experience  of  a  previous  delivery  which  had  been' 
followed  by  symptoms  of  uterine  inflammation.  The  mischief, 
however,  dates,  I  believe,  in  all  instances,  not  from  any  particular 
epoch  of  pregnancy,  but  from  the  expulsion  of  the  ovum  when- 
ever that  occurs;  and  the  greater  hazard  attendant  upon  labors 
at  the  full  period,  is  due  to  the  greater  violence  undergone  by 
the  uterus  and  the  tumor  during  the  passage  of  the  foetus  in  ad- 
vanced than  in  early  pregnancy.  Each  case,  then,  must  be  con- 
sidered and  treated  on  its  own  merits  ;  the  mere  fact  of  a  pregnant 
woman  having  a  fibrous  tumor  of  her  uterus,  cannot  be  taken  as 
a  sufficient  indication  for  the  induction  of  abortion  or  of  premature 
labor. 

1  A  second  case,  almost  identical  in  its  features  with  the  foregoing,  and,  like  it, 
having  a  fatal  termination,  came  under  my  notice  in  1862,  and  has  been  report.ed 
by. Dr.  3Iadge,  in  the  fourth  volume  of  the  Obstetrical  Transactions. 


UTERINE    TUMORS    AND    OUTGROWTHS.  259 


LECTURE    XVII  I. 

UTERINE  TU-AIORS  AXD  OUTGROWTHS. 

FiBRors  Polypi  ;  their  structure,  vascular  supply,  and  source  of  liemorrliage 
which  attends  them.  Their  symptoms.  Operations  I'or  their  removal ;  com- 
parative merits  of  ligature  and  excision.  Management  of  labor  complicated 
with  polypus. 

Rkcukkknt  Fibroid  Tumors  of  Uterus.     Their  rarity  ;  illustrative  cases. 

Fatty  Tumors  of  Utkrus. 

Tubercular  Degeneration  of  Uterus.  Its  characters,  seat  of  the  disease,  and 
connection  with  general  tuberculosis. 

It  still  remains  for  us  to  consider  that  variety  of  uterine  fibrous 
tumor  wliicb  grows  from  the  inner  surface  of  the  womb,  or  which 
less  frequentl}'  spi'inging  from  eitber  lip,  hangs  down  by  a  stalk 
or  pedicle  into  tlie  cavity  of  the  uterus,  or  into  the  cana]  of  the 
vagina.  Tlie  impropriety  of  the  term  Polypus,  as  applied  to  these 
solid  growtbs,  need  not  occupy  us  now;  it  is  sufficient  that  it  has 
been  universally  adopted,  and  is  so  well  understood,  that  no  one 
will  be  misled  by  the  incorrect  terminology. 

In  general  structure  these  tumors  are  almost  identical  with 
those  we  have  hitherto  been  studying;  the  only  important  dili'er- 
ence,  perhaps,  being,  that  whereas  the  growth  in  all  the  former 
cases  was  distinct  from  the  uterine  tissue,  even  though  imbedded 
in  it,  or  projecting  from  it,  some  polypi  are  positive  outgrowths  of 
uterine  tissue,  their  texture  and  that  of  the  womb  'itbelf  being 
inextricabl}^  interwoven.^  Even  in  these  instances,  however,  the 
substance  of  the  growth  is  usually  firmer,  denser,  and  less  vascular 
than  that  of  the  adjacent  uterine  wall ;  while  on  the  other  hand, 
the  pediculated  fibrous  tumor  is  generally,  when  growing  from 
the  interior  of  the  womb,  more  succulent  and  better  su}iplied 
with  blood  tlian  similar  tumors  whose  position  and  relations  are 
different.  The  pedicle  of  these  tumors  is  composed  of  uterine  sub- 
stance mingled  with  more  or  less  dense  cellular  tissue,  and  though 
generally  single,  is  sometimes  formed  by  the  coalescence  of  two 
or  three  bundles  of  fibres  springing  from  different,  though  nearly 
adjacent,  ])arts  of  the  womb.  A  layer  of  uterine  substance  is  con- 
tin  ued  from  the  pedicle  for  a  varying  distance  along  the  tumor, 
sometimes  investing  it  completely,  at  other  times  only  in  part,  as 
the  cup  surrounds  the  acorn,  or  the  calyx  the  petals  of  a  fiower. 
Besides  this,  the  polypus  is  always  covered  by  the  mucous  mem- 
brane of  the  uterus,  which  becomes  firmer  and  denser  than  natural, 
both  it  and  also  the  muscular  fibres  of  the  womb  itsolf  undergo- 
ing development  somewhat  in  i)roportion  to  that  of  the  tumor. 
The  tumor  can  often  be  shelled  out  of  its  coverings  just  in  the 

1  As  in  a  ]iri'parati()n  in  tlie  M usciim  of  St.  Barthr)lomew's  riospitnl,  sketched 
and  referred  to  b}'  Paget,  op.  cit.,  vol.  ii,  p.  131,  tig.  11. 


260  FIBROUS   polypi: 

same  manner  as  an  ordinary  fibrous  tumor  may  be  enucleatccl  from 
its  investment  of  dense  cellular  tissue  ;  but  this  is  not  invariably 
the  case,  and  the  connection  between  the  substance  of  the  polypus 
and  the  membrane  that  surrounds  it  is  now  andthen  very  i)itimate. 
The  vascular  supply,  as  already  stated,  is  more  abundant  than  that 
of  other  fibrous  tumors,  though  it  may  generally  be  observed  that 
neither  the  arterial  trunks  entering  the  tumor  nor  the  veins  leav- 
ing it  are  proportionate  in  size  to  what  might  be  anticipated  from 
the  quantity  of  blood  in  its  substance.  Some  part  of  its  supply 
of  blood  alrfo  comes  to  the  polypus  through  the  mucous  membrane 
by  wdiich  it  is  invested,  though  even  in  tliis  no  considerable  ves- 
sels are  in  general  perceptible.  This  comparatively  small  apparent 
supply  of  blood  to  these  tumors,  coupled  with  the  fact  that  they 
always  give  rise  to  very  profuse  hemorrhage,  while  such  hemor- 
rhage is  always  arrested  by  a  ligature  applied  jrouud  their  peflicle, 
have  contributed  to  form  a  problem  in  uterine  patholog}-,  wliich, 
till  within  a  recent  date,  received  very  conflicting  and  very  un- 
satisfactory solutions.  The  profuse  bleeding  which  is  excited 
alike  by  non-pediculated  fibrous  tumors,  and  also  by  the  very 
minute  vascular  polypi  of  the  organ,  seems  to  show  that  it  is 
rather  from  the  irritated  mucous  membrane  of  the  uterus  than 
from  the  surface  of  the  tumor  itself  that  the  bleeding  flows.  The 
same  fact,  too,  is  further  illustrated  by  facts  such  as  the  following  : 
A  woman,  aged  forty-six,  was  admitted  under  my  care  into  St. 
Bartholomew's  Hospital.  She  was  a  single  woman,  and,  with  the 
exception  of  a  sense  of  weight  at  the  lower  part  of  the  abdomen, 
since  the  cessation  of  her  menses  at  the  age  of  forty-three,  liad  had 
good  health  "till  three  weeks  before  she  came  under  my  notice. 
She  was  then  suddenly  attacked  by  profuse  hemorrhage,  and  at 
the  same  time  a  tumor  had  partially  forced  its  way  through  her 
vulva.  The  loss  of  blood  had  continued  more  or  less  since,  and 
the  patient,  at  her  admission,  seemed  very  much  exhausted  by  it. 
This  tumor,  which  at  its  lower  part  was  already  in  a  state  of  super- 
ficial slough,  was  a  fibrous  tumor  which  measured  seven  inches 
in  length  by  four  in  diameter  at  its  widest  part,  and  w'eighed  one 
pound  one  ounce  and  a  half.  It  was  connected  by  a  small  and 
short  pedicle  with  the  posterior  lip  of  the  uterus ;  an  arterial 
trunk  about  the  size  of  one  of  the  digital  arteries  seemed  to  be  the 
source  whence  its  supply  of  blood  w'as  derived;  though  it  pre- 
sented an  unusual  degree  of  vascularity,  and  its  lower  part,  which 
had  projected  beyond  the  vulva,  and  had  been  subjected  to  pres- 
sure, w^as  so  intensely  congested  as  to  have  an  almost  apoplectic 
appearance.  Now  this  large  and  vascular  growth  had  gone  on, 
doubtless  for  years,  increasmg  in  size,  and  yet  producing  no  symp- 
toms, giving  rise  to  no  hemorrhage,  until  having  partially  escaped 
beyond  the  vulva,  it  began  to  drag  upon  the  womb,  to  pull  it  down- 
wards, and  to  irritate  it,  and  then  all  at  once,  from  the  womb  itself, 
for  there  was  no  appearance  of  bleeding  from  any  part  of  the  sur- 
face of  the  tumor,  sudden  and  most  formidable  hemorrhage  broke 
forth.     The  suspension  of  bleeding  by  the  application  of  a  ligature 


SOURCE    OF    IIEM0RRHA(;E,  2G1 

around  tlie  pedicle  of  a  polypus  does  not  of  necessity  imply  that 
the  source  whence  the  heniorrhaire  proceeded  is  thus  mechanically 
shut  off,  but  is  also  inteHigible*x)n  the  supposition  that  the  ligature 
interrupts  the  vital  relations  between  the  tumor  and  the  womb, 
and  thus  renders  the  polypus  a  far  less  powerful  excitant  of  the 
uterine  mucous  membrane  than  it  was  before.  No  stronger  proof 
can  be  aflorded  of  tlio  difference  between  a  vital  and  a  mere 
mechanical  stimulant  of  the  uterus  than  is  given  by  the  compara- 
tive impunity  with  which,  in  many  instances,  the  metallic  stem 
of  the  uterine  supporter  is  borne  within  the  cavity  of  the  womb, 
as  contrasted  with  the  almost  irrestrainable  hemorrhages  that  are 
often  excited  In*  even  the  smallest  vascular  polypi. 

Fibrous  l>olypi  are  susceptible  of  the  same  kinds  of  changes  as 
may  take  place  in  fibrous  tumors  elsewliere  situated.  I  am  not 
aware,  however,  of  their  undergoing  that  atrophy  which  occa- 
sionally occurs  in  other  fibrous  tumors  of  the  uterus,  while  cal- 
careous deposits  in  their  substance  are  excessively  rare.  On  the 
other  hand,  both  oedema  of  their  substance,  and  the  extravasation 
of  blood  into  their  tissue,  are  far  from  being  of  unusual  occurrence; 
and  when  tlic}^  have  passed  through  the  os  uteri  into  the  vagina,  the 
membrane  covering  their  lower  surface  not  infrequently  becomes 
ulcerated,  or  passes  even  into  a  sloughing  condition,  which  may 
extend  to  the  adjacent  substance  of  the  growth.  They  do  not, 
however,  so  far  as  I  know,  ever  shell  out  completely  from  their 
investment  as  some  other  fibrous  tumors  now  and  then  do;  and 
when  S[>ontaneonsly  detached  and  expelled,  their  natural  cure  is 
brought  about  by  their  pedicle  giving  way. 

Formed,  as  these  polypi  usually  are,  within  the  cavity  of  the 
uterus,  their  influence  upon  that  organ  seems  to  depend  somewhat 
on  the  situation  whence  they  spring.  Thus  if  it  arise  low  down 
in  the  cervical  canal,  the  tumor  soon  grows  beyond  these  limits, 
and  hanging  down  into  the  vagina,  may  acquire  a  considerable 
size  without  exerting  much  influence  on  the  womb  itself,  neither 
disturbing  its  functions  nor  producing  any  consideralde  hyper- 
trophy of  its  tissue.  On  the  other  hand,  those  polypi  which  are 
developed  from  some  point  high  up  in  the  womb,  naturally  remain 
within  its  cavity  till  they  have  acquired  a  consideral»le  size,  and 
thus  give  rise  to  enlargement  of  the  organ,  and  to  thickening  of  its 
walls.  There  seem,  however,  to  be  considerable  diversities  between 
the  relations  which  the  polypus  continues  to  bear  in  different  cases 
to  the  organs  within  which  it  is  developed.  In  the  great  majority 
of  instances,  before  it  has  acquired  the  size  of  a  small  apple,  tlie 
OS  uteri,  against  which  the  lower  |)art  of  the  polypus  lies,  gradually 
dilates  to  allow  its  passage,  and  the  growth  is  then  found  hanging 
down  into  the  vagina,  its  pedicle  embraced,  though  but  seldom 
tightly  constringed,  by  the  orifice  of  the  womb.  Sometimes,  liow- 
ever,  I  know  not  why,  this  process  is  eftected  much  less  quickly; 
the  margins  of  the  os  uteri  do  not  yield  so  as  to  allow  of  tlie  easy 
exit  of  the  polyjuis,  but  violent  uterine  action  is  set  up,  and  under 
efibrts  like  those  of  labor,  and  which  recur  in  paroxysms,  and 


262  SYMPTOMS    OF    FIBROUS     POLYPI: 

tlien  subside,  and  again  recur  after  a  lapse,  perhaps,  of  many 
days,  the  polypus  is  literally  born.  It  is  usually  under  these  vio- 
lent throes  that  the  womb,  as  was 'Explained  in  a  former  Lecture,* 
sometimes  becomes  literally  inverted,  or  turned  inside  out ;  an 
accident  which  is  brought  about  less  by  the  mere  mechanical  action 
of  the  weight  of  the  tumor  than  by  the  eflbrts  which  it  excites  in 
the  muscular  tissue  of  the  womb. 

When  once  in  the  vagina,  the  growth  of  the  polypus  still  goes 
on,  and  probably  even  more  rapidly  than  before,  since  it  is  no 
longer  subjected  to  the  same  degree  of  pressure  as  while  it  was 
within  the  uterus.  For  the  most  part,  however,  the  symptoms  to 
which  it  has  given  rise  have  been  so  serious  as  to  lead  to  its  early 
detection,  and  it  is  removed  before  it  has  acquired  any  very  for- 
midable dimensions.^  If  it  be  allowed  to  sojourn  for  any  time  in 
the  vagina,  that  part  of  the  tumor  to  which  the  air  has  access 
seldom  fails  to  become  ulcerated,  while  it  is  further  by  no  means 
unusual  for  the  adjacent  surface  of  the  vagina  to  become  likewise 
inflamed  and  ulcerated,  and  for  adhesion  then  to  take  phice  between 
the  two.  A  similar  occurrence  happens  occasionally,  though  much 
less  often,  between  the  tumor  and  the  lining  membrane  of  the 
uterus  itself;  and  either  of  these  accidents  may  make  the  diagnosis 
obscure,  and  must  render  all  forms  of  operative  interference  un- 
usually difficult. 

The  two  grand  symptoms  of  polypus  uteri  are  hemorrhage  and 
leucorrhoea,  symptoms  which  go  on  increasing  in  severity  and 
continuance  until,  if  tlieir  cause  be  undiscovered  or  unremoved, 
they  will  at  length  exhaust  and  destroy  the  patient.  At  first  the 
seasons  of  menstruation  are  those  when  the  hemorrhage  takes 
place,  the  periods  lasting  longer,  returning  sooner,  and  being  ac- 
companied with  a  more  profuse  loss  than  was  their  wont,  while 
abundant  leucorrhcea  persists  in  their  intervals.  Then  the  periodi- 
city of  the  hemorrhage  ceases,  for  its  presence  becomes  general,  or 
constant,  and  it  is  at  leYigth  found  impossible  to  keep  any  account 
of  when  menstruation  last  took  place,  or  when  it  may  next  be  ex- 
pected. 

A  constant  sense  of  bearing  down  may  be  experienced,  or  some 
mechanical  inconvenience  or  other,  from  the  pressure  of  the  poly- 
pus, if  large,  upon  adjacent  parts;  or  expulsive  eflbrts  may  some- 
times occur;  but  they  are  by  no  means  constant;  and  the  last- 
mentioned  symptom  in  particular  is  met  with  only  in  a  small 
minority  of  cases.  It  has  been  said  that  the  escape  of  coagula  of 
an  annular  shape,  due  to  their  being  formed  around  the  pedicle  of 
the  polypus,  is  characteristic  of  this  aftection.  This,  however,  is 
one  of  those  plausibilities  which  savor  more  of  the  study  than  of 

1  See  Lecture  XIII,  on  Inversion  of  the  Uterus,  p.  187. 

2  I  have  already  mentioned  one  case  where  the  polypus  weighed  1  lb.  IJoz.  An 
instance  is  related  by  Heyfelder,  Studieji  im  Geblete  der  Heilwissenschnfi,  8vo, 
Stuttgart,  1838,  vol.  i,  p.  269,  of  a  polypus  which  weighed  1  lb.  3  oz.  7  d'r.  ;  and 
numerous  references  are  given  by  Meissner,  op.  cit.,  vol.  i,  p.  838,  to  cases  of  polypi 
of  enormous  dimensions. 


THEIR    DIAGNOSIS.  263 

the  bedside,  and  experience  does  not  confirm  the  statement.  The 
only  rule,  indeed,  which  I  can  give  you  as  to  the  diagnosis  of 
polypi  is,  that  whenever  hemorrhage,  having  taken  place  cause- 
lessly at  one  menstrual  period,  recurs  equally  without  cause  at  the 
succeeding  one,  you  should  on  no  account  omit  making  a  vaginal 
examination.  The  tumor  projecting  through  the  os  uteri,  encir- 
cled by  its  lips,  and  passing  up  into  its  cavity,  perhaps  boA'ond  the 
point  to  which  3'our  tliiger  can  reach,  can  scarcely  be  mistaken  for 
anything  else,  except,  perhaps,  for  the  inverted  uterus,  the  distinc- 
tive characters  of  which  I  have  already  endeavored  to  point  out.^ 
Neither,  indeed,  can  the  nature  of  those  polypoid  growths  which 
proceed  from  one  or  other  lip  of  the  uterus  be  doubtful,  since 
the  OS  uteri  will  be  perceptible  either  in  front  of  the  growth  or 
behind  it.  , 

In  cases  where  tlie  polypus  lias  not  3'et  passed  through  the  os 
uteri,  the  diagnosis  may  be  very  difficult,  for  hemorrhage  and 
leucorrhoeal  discharge  are  common  to  many  uterine  ailments,  while 
the  growth  itself  may  not  be  sufficiently  large  to  produce  any 
marked  increase  in  the  size  of  the  wondj,  still  less  to  expand  its 
lower  segment.  In  doubtful  cases  the  uterine  sound  is  often  of 
much  service,  since  as,  by  means  of  it,  we  ascertain  either  that  the 
uterine  cavity  exceeds  its  natural  dimensions,  or  is  limited  to  them, 
so  the  presumption  in  favor  of  the  presence  of  some  tumor  in 
the  womb  is  either  greatly  strengthened,  or  altogether  refuted. 
Sometimes,however,  the  introduction  of  the  sound  is  very  difficult, 
or,  from  its  extremity  impinging  on  the  body  of  the  tumor,  is 
altogether  impossible;  while  even  at  the  best,  though  the  sound 
may  raise  our  presumption  of  the  existence  of  a  polypus  almost  to 
a  certainty,  we  are  not  thereby  at  all  assisted  towards  its  removal. 
Tiie  ingenuity  of  Professor  Simpson,^  however,  has  furnished  us, 
in  the  sponge  tent,  with  a  means  by  wliich  we  can  readily  dilate 
the  OS  uteri  sufficiently  to  make  a  careful  examination  of  the 
interior  of  the  womb,  and  to  perform  any  ojieration  which  the 
tumor  may  call  for,  almost  as  easily  as  if  it  had  already  descended 
into  the  vagina. 

This  brings  me,  in  conclusion,  to  consider  the  best  means  of 
removing  these  ilbrous  polypi  of  the  uterus,  for  I  will  not  waste 
your  time  in  repeating  again  all  the  measures  by  which  you  must 
try  for  the  moment  to  stanch  the  profuse  hemorrhage  to  which 
these  growths  sometimes  give  rise.  Now  there  are  two  ditlerent 
proceedings,  each  of  which  has  been  strenuously  advocated  by 
some  persons,  and  equally  strongly  reprobated  by  others.^  One  of 
these  consists  in  strangulating  the  growth  by  means  of  a  ligature, 
the  other  in  its  excision  with  the  scissors  or  some  other  cutting 
instrument.     The  apprehension  of  dangerous  bleeding  from  the 

1  See  p.  199. 

2  On  the  Defpcfion,  i\c.,  of  hitra-}iferine  Polypi,  \n  Ed.  Mont/ih/  JoKinnI,  Ann.  18.")0, 
and  Obstetric  Memoirs,  vol.  i,  p.  1*22. 

*  See  a  pa|)er  by  Dr.  Simpson,  Obstetric  Memoirs,  vol.  i,  p.  150,  strongly  con- 
demnatory of  the  u.-^e  of  the  ligature. 


264  COMPARISON    OF    LIGATURE 

removal  of  polypi,  to  which  mistaken  anatomical  views  in  a 
measure  contributed,  led  to  the  adoption  of  the  ligature  in  the  first 
instance;  but 'its  use  has  now,  with  propriety,  been  almost  uni- 
versally abandoned.  The  reasons  for  the  discontinuance  of  its 
employment  are,  that  the  application  of  the  ligature  is  almost 
always  tedious,  often  difhcult;  that  while  in  the  case  of  the  smaller 
polypi  and  of  those  with  thin  pedicles,  its  employment  is  super- 
fluous, its  action  when  the  pedicle  is  thick  is  both  slow  and  uncer- 
tain, and  it  of  necessity  condemns  the  patient  for  days  to  all  the 
discomforts  arising  from  the  decay  of  the  strangulated  tumor. 
But  further,  the  operation  is  attended  not  merely  by  discomfort, 
but  also  by  positive  danger,  partly  from  the  tissue  of  the  uterus 
itself  being  almost  unavoidably  included  in  the  ligature,  partly 
from  the  risk  of  phlebitis  being  set  up  by  the  absorption  of  the 
putrid  debris  of  the  decaying  polypus.  That  these  dangers,  too, 
are  far  from  being  imaginary,  you  may  satisfy  yourselves  by  visit- 
ing any  of  the  anatomical  museums  of  tliis  metropolis,  all  of 
which  I  think  you  will  find  contain  specimens  of  polypi  partially 
detached,  or  of  uteri  from  which  the  growth  had  been  quite  sepa- 
rated by  ligature,  but  in  which  the  supervention  of  inflammation 
had  destroyed  the  patient. 

The  reason  alleged  for  the  preference  of  the  ligature  to  the 
excision  of  l>olypi  is  the  risk  of  hemorrhage  attending  the  latter 
operation.  My  own  experience  of  twenty  cases  of  excision  of 
fibrous  polypi  unattended  by  hemorrhage,  is  too  small  to  be  of 
much  weight;  but  Velpeau'  states  that  no  instance  of  troublesome 
hemorrhage  occurred  to  him  in  twenty  cases  in  which  he  excised 
polypi ;  Lisfranc^  states  that  he  met  with  it  in  but  two  out  of  165 
cases;  and  Dupuytren^  also  in  l)ut  two  out  of  nearly  200;  while 
they  all  refer  to  instances  of  phlebitis,  or  of  peritoneal  inflamma- 
tion leading  to  a  fatal  issue  after  the  operation  by  ligature.  There 
are,  indeed,  a  few  instances  on  record  of  inflammatory  symptoms 
succeeding  to  the  excision  of  polypi,  just  as  there  are  a  few  in 
which  dangerous  hemorrhage  has  followed  their  removal  by  liga- 
ture ;  and  in  one  instance  under  my  care,  'peritonitis  came  on  on 
the  fourth  and  terminated  fatally  on  the  tenth  day,  after  the  easy 
excision  of  a  small  fibrous  polypus.  I  believe  that  on  the  whole 
the  advantages  of  the  former  operation  greatly  preponderate ;  that 
it  is  much  easier,  much  more  speedy,  and  much  safer ;  and  that 
the  cases  are  very  few  in  which  it  will  not  be  found  the  better  pro- 
ceeding. In  this  opinion,  too,  there  is  an  almost  unanimous  con- 
currence on  the  part  of  those  whose  experience  has  been  most 
extensive;^  though  in  order  to  guard  against  the  possibility  of 
hemorrhage  occurring,  some  few,  as  for  instance  M.  Aran,^  prefer, 

1  Medecine  Operaioire,  t.  iv,  2d  ed.,  p.  391. 

2  dhdrpie  Clilrurgicale  de  la  Pitie,  t.  iii,  p.  210. 
^  Schmidt,  Jnhrh.^  vol.  ii,  p.  90. 

■•  It  may  .=iifi5ce  to  refer  to  the  names  of  Scanzoni,  Aran,  and  McCliiitock,  in 
siijiport  of  this  statement. 
*  Oj).  clt.,  p.  87o. 


AND    EXCISION     OF    POLYPI.  265 

wlierever  it  is  practicable,  to  apply  the  ligature,  and  tlien,  either 
at  once  or  very  soon  after,  to  excise  the  growth. 

Considering  the  opinion  which  I  entertain  concerning  the  com- 
parative merits  of  the  operation  by  ligature  and  that  l)y  excision, 
it  can  scarcely  be  expected  that  I  should  enter  into  any  lengthened 
details  with  reference  to  the  former  mode  of  extirpating  iiolyj)!, 
or  the  different  instruments  which  have  been  invented  for  the 
purpose.  It  may  suffice  to  say  that  on  the  wliole  Gooch's  double 
canula,  with  the  contrivance  invented  by  Laundy,  the  instrument- 
maker  in  the  Borough,  for  tightening  the  ligature,  appears  to  me 
the  most  easy  of  application,  and  most  generally  suitable  ;  though 
nothing  can  better  illustrate  the  great  difficulty  often  experienced 
in  tying  polypi  than  the  number  of  the  instruments  which  have 
been  devised  with  this  end.' 

The  excision  of  polypi  is  very  seldom  indeed  attended  by  much 
difficulty,  or  even  by  so  much  pain  as  to  necessitate  the  use  of 
chloroform,  though,  if  the  patient  be  nervous,  there  can  be  no 
possible  objection  to  its  employment.  The  patient  being  placed 
on  her  back,  with  the  feet  resting  on  a  stool,  and  the  knees  sepa- 
rated and  firmly  held  apart  by  assistants,  a  pair  of  Museux  hooks 
are  to  be  carefully  carried  along  the  index  finger  of  the  left  hand 
of  the  operator  as  high  as  the  pedicle  of  the  tumor.  They  nnist 
then  be  carefully  sei^irated  ;  two  fingers  of  the  left  hand  guarding 
their  hooked  extremities  until  they  are  sufficiently  far  a})art  to 
allow  of  the  pedicle  being  seized  by  them  firmly.  If  the  polypus 
be  but  small,  a  single  pair  of  hooks  will  suffice  to  hold  it  securely, 
and  the  poljqius  may  now  be  steadily  but  gently  drawn  down  be- 
yond the  external  parts,  or  at  any  rate  close  to  the  vulva,  when 
its  stalk  may  be  divided  by  a  pair  of  stout,  curved,  probe-pointed 
scissors,  similar  to  those  wliicli  surgeons  use  in  operations  on  the 
tongue.  If,  however,  the  first  pair  of  hooks  be  not  fixed  very 
firmly,  or  if  the  tumor  be  of  considerable  size,  so  as  not  to  yield 
to  traction  readily,  it  may  be  expedient  to  introduce  a  second  or 
even  a  third  pair  of  hooks  before  nudving  any  extractive  efforts. 
In  this  case  it  is  often  convenient  to  introduce  each  hook  and  fix 
it  separately,  which  is  easily  enough  done,  by  having  the  instru- 
ment made  as  my  former  colleague,  Mr.  Arnott,  was  accustomed, 
with  the  two  halves  separate,  but  capable  of  being  united  by  a 
lock  like  that  of  the  common  midwifery  forceps.  Even  when  thus 
contrived,  how^ever,  if  the  polypus  be  large,  so  as  nearly  to  fill  the 
vagina,  a  sharp  hook  cannot  be  carried  high  up  so  as  to  hiy  hold 
of  its  iiedicle  without  a  u'ood  deal  of  risk  of  getting  entangled  as 
it  is  passed,  or  of  prickling  the  operator's  fingers  severely.  A' 
metal  sheath  which  I  have  had  made  for  covering  these  liooks, 
and  wdiich  can  be  immediately  dislodged,  as  soon  as  they  have 

1  An  olaboratc  critiquo  of  the  difl'crent  instrumonts  for  tying  ]ioly]>i  is  given  by 
Kilian,  Opcra/ion.slc/ire  f.  Gcbnrl.HhUlfcr,  2cl  ctl.,  Bonn,  1852,  part  ii,  j.p.  '-'08-248. 
Dr.  Gooch  himself  describes  his  own  cannla  and  its  mode  of  apjilieation  at  pp. 
2r)n-2Gr)  of  liis  \vorl<  on  the  Dixcnse.t  of  Wvinen,  so  ch'arly,  that  no  better  rules  can 
be  laid  down  for  the  uso  of  the  ligature. 


266  RULES    FOR     THE 

been  carried  to  the  part  of  the  tumor  into  which  it  is  wished  to 
fix  them,  very  readily  overcomes  this  difficulty.  Steady  traction 
seldom  fiiils  to  bring  the  growth  within  reach  of  the  scissors, 
though  I  have  known  it  to  be  requisite  to  employ  the  midwifery 
forceps  to  bring  a  large  polypus  through  the  vulva.  Lisfranc  was 
accustomed,  in  cases  where  there  was  much  difficulty  in  dragging 
down  the  polypus,  to  fix  the  hooks  into  the  lips  of  the  uterus,  and 
then  to  make  traction  directly  on  the  womb  itself.  Neither  this 
proceeding,  however,  nor  that  of  incising  the  perineum  in  cases 
where  the  large  polypus  could  not  pass  the  narrow  vulva,  and 
which  has  the  authority  of  Dupuytren  in  its  support,  seems  to  me 
ex|»edient. 

The  division  of  a  large  polypus,  and  its  extraction  piecemeal, 
has  been  proved  by  experience  to  be  unattended  by  any  of  those 
risks  of  hemorrhage  which  were  once  apprehended  from  the  em- 
ployment of  cutting  instruments  in  any  way  for  the  extirpation  of 
these  tumors;  while  various  practitioners  have  invented  curved 
knives  or  cutting  hooks  for  the  division  of  the  pedicle  of  polypi 
which  could  not  be  drawn  down  with  facility.  Thus  M.  Vel[>eau^ 
employs  a  knife  eight  or  ten  inches  in  length,  curved  at  its  point, 
which  is  blunt,  and  has  a  cutting  edge  only  on  one  side.  With 
this  instrument  he  divides  the  pedicle  of  the  polypus,  which  is  kept 
on  tlie  stretch  by  an  assistant  grasping  it  with  a  pair  of  Mnseux 
hooks.  A  very  ingenious,  though  perhaps  rather  complicated 
knife,  the  blade  of  which  is  fixed  at  right  angles  with  the  handle, 
and  is  introduced  defended  by  a  sort  of  sheath,  like  that  of  a  bistoire 
cache,  was  invented  and  used  in  a  case  where  the  polypus  was  very 
large,  and  its  pedicle  very  thick  and  solid,  by  Dr.  Herrich,  of 
Ratisbon,^  while  more  lately  Professor  Simpson,  of  Edinburgh,^ 
has  employed  an  instrument  not  unlike  the  sharp  hook  employed 
by  midwifery  practitioners  for  decapitating  the  foetus.  The  in- 
strument seems  in  his  hands  to  have  answered  very  well,  though 
one  might  have  feared  that  the  sharp  edge  being  on  the  same  i)lane 
with  the  handle  of  the  instrument,  it  would  have  cut  too  obliquely 
for  the  ready  division  of  the  pedicle. 

Though  thus  generally  applicable,  there  are,  however,  a  few  con- 
ditions in  which  excision  of  polypi  appears  to  be  inferior  in  safety 
to  their  removal  by  ligature.  The  forcible  drawing  down  of  the 
uterus  in  cases  where  a  polypus  is  contained  within  its  cavity,  in 
order  to  obtain  access  to  the  growth,  is  inevitably  accompanied 
with  a  degree  of  violence  which  is  avoided  in  the  application  of 
the  ligature.  The  employment  of  the  steel  wire  rope  instead  of 
the  old  whip-cord  ligature,  and  tlie  application  of  the  principle  of 
the  ecraseur,  as  in  the  instrument  invented  by  Dr.  Braxton  Hicks,* 

1  Bull.  Gen.  de  Therapeutique,  vol.  xiv,  Paris,  1838,  p.  1856  ;  and  Meissner,  op. 
cit.,  vol.  i,  p.  864. 

2  Ueher  Gebdrmutter  Pobjpen  imd  deren  Aysrottung,  8vo.,  Regensburg,  1846. 
8  Edi7i.  Monthly  Journal,  Jan.  1855,  and  Obstetric  Worka,  vol.  i,  p.  150. 

*  See  the  description  and  drawing  of  the  instrument  in  Transactions  of  the  Obstet- 
rical Society,  vol.  iii,p.  346. 


EXCISION     OF    POLYPI.  267 

deprives  the  ligature  of  the  danger  which  used  to  accompany  it, 
since  by  this  means  the  pedicle  of  the  outgrowth  may  be  cut 
through  in  a  few  minutes.  In  cases  of  very  large  polypi,  in  which 
there  is  no  space  for  the  application  of  other  instruments,  this 
cutting  ligature  may  ah^o  probably  be  employed  with  safety.* 

By  whatever  means  a  polypus  is  separated  from  tlie  uterus 
(polypi  of  a  malignant  character  of  course  excepted),  the  pedicle 
withers,  and  the  growth  is  not  reproduced.  This  fact,  which  was 
once  regarded  as  suggesting  a  problem  of  difficult  solution,  is  not 
hard  to  understand,  if  we  bear  in  mind  that  the  pedicle  is  formed 
of  uterine  tissue.  On  the  removal  of  the  growth,  the  stimulus  to 
hypertrophy  of  the  uterus  is  withdrawn,  the  whole  organ  returns 
by  that  process  of  involution  of  which  we  see  so  many  illustrations 
to  its  natural  dimensions,  while  the  pedicle  of  the  polypus,  having 
no  longer  any  office  to  perform,  is  completely  removed. 

Other  modes  of  getting  rid  of  fibrous  pol_ypi  have  been  occa- 
sionally resorted  to,  but  it  is  scarcely  necessary  to  do  more  than 
enumerate  them.  Torsion  is  but  rarely  applicable,  for  the  pedicle 
is  usually  too  thick  and  too  firm  to  admit  of  the  growth  being  thus 
removed.  If  the  polj^pus  be  small,  and  its  stem  slender,  there  can, 
however,  be  no  objection  to  it,  while  it  unquestionably  has  the 
great  advantage  of  doing  away  almost  completely  with  all  risk  of 
bleeding.  The  forcible  tearing  away  or  avulsion  of  the  growth 
has  nothing  whatever  to  recommend  it;  it  is  uncertain,  painful, 
and  hazardous.  The  destroying  the  vitality  of  the  polypus  by 
forcible  compression,  either  of  the  whole  mass,  or  by  an  instru- 
ment strangulating  its  pedicle,  as  practised  by  M.  Gensoul,  of 
Lyons,^  appears  open  to  all  the  objections  that  may  be  alleged 
against  the  ligature,  without  any  compensating  advantage. 

Some  reference  ought,  perhaps,  to  be  made  to  the  occasional 
complication  of  pregnancy  or  labor  with  polypus  of  the  uterus, 
before  we  take  a  final  leave  of  this  subject.^  There  seems  to  be 
good  reason  for  believing  that  polypi  participate  in  the  general 
development  of  the  uterus  during  pregnane}',  and  tluit  a  growth 
previously  very  small  may  attain  to  a  very  considerable  size  during 
gestation.  They  do  not,  however,  in  general  produce  mai"ked 
symptoms  during  pregnancy,  nor  do  they  tend  to  interfere  with 
its  natural  progress.  After  the  commencement  of  labor  their  in- 
jurious effects  become  manifest,  since  they  sometimes  present  a 

1  Dr.  G.  Simon,  who  has  done  so  much  for  tho  improvement  of  operative  sur- 
gery in  tho  diseases  of  women,  suggests  a  very  ingenious  mode  of  obtaining  access 
to  the  pedicle  of  very  voluminous  polyju.  This  proceeding  consists  in  making  a 
deep  transverse  incision  as  high  as  |)ossible  into  the  body  of  the  polypus,  and  tln-n 
dissecting  off  its  capsule  from  half  the  circumference  of  the  growtli.  If  ii<>\v  the 
polypus  is  seized  with  hooks,  and  steady  traction  nnide  ui)on  it,  Us  films  will  don- 
gate  to  such  an  extent  as  to  allow  ready  access  to  the  pedicle,  though  before,  while 
the  mass  retained  a  more  globular  form,  it  might  have  been  altogether  out  of  reach. 
[Afo7infschnft  f.  Grhiirtskuiulc,  vol.  xx,  p.  4(;7.)  ^ 

'■^  Nouveau  Proce((6  pour  operer  les  Po/i/pes  de  Mntrice,  8vo.,  Lyons,  18.")1,  p.  11. 

8  A  very  able  essay  on  this  subject,  which  will  well  repay  perusal,  was  published 
by  Dr.  Oldbam  in  the  Guy's  Hospital  Reports,  2d  series,  vtd.  ii. 


268  *  RECURRENT    FIBROID    TUMOR. 

meclianical  obstacle  to  the  passage  of  the  cliild,  and  at  other  times 
give  rise  to  untoward  consequences  after  its  expulsion.  Of  these, 
one  of  the  most  frequent  is  hemorrhage ;  the  polypus  within  the 
uterine  cavity  interfering  with  the  due  contraction  of  the  organ, 
just  as  the  portion  of  adherent  placenta  does  in  cases  of  its  disrup- 
tion. The  other  risk  is  that  of  violent  and  uncontrolUible  uterine 
action  being  excited,  and  exhausting  the  patient  by  its  severity 
and  continuance,  as,  for  instance,  in  tlie  remarkable  case  related 
by  Dr.  Gooch,^  in  which,  after  delivery,  a  polypus  weighing  three 
pounds  fifteen  ounces  was  expelled  beyond  the  external  parts,  and 
the  patient  died  while  her  medical  attendants  were  still  uncertain 
as  to  what  her  ailment  was,  and  what  should  be  done  for  her  cure. 

In  spite  of  these  contingencies,  however,  the  general  rule,  and 
one  concerning  the  wisdom  of  Avhich  there  can  be  no  doubt,  is  not 
to  meddle  with  a  uterine  polypus  either  in  labor  or  after  delivery, 
unless  the  symptoms  are  so  serious  as  to  leave  us  no  alternative. 
The  ground  for  this  rule  is  furnished  by  the  risk  of  hemorrhage  if 
the  polypus  be  excised,  and  of  phlebitis  from  the  absorption  of 
decaying  a^iimal  matter  if  the  growth  be  removed  by  ligature ; 
while  the  vascularity  of  the  polypus,  and  probably  its  size,  will 
rapidly  diminish  as  the  involution  of  the  uterus  goes  on,  and  the 
whole  organ  grows  less  and  less  susceptible  as  the  date  of  delivery 
becomes  more  distant. 

It  is  therefore  better  during  labor  to  extract  the  child,  and  after- 
wards to  check  hemorrhage,  and  by  opiates  to  still  any  violent 
uterine  efibrts,  if  possible,  rather  than  by  attempting  the  immediate 
removal  of  the  polypus,  to  expose  the  patient  to  hazards  so  serious 
and  so  difficult  to  obviate.  If,  however,  interference  become 
urgently  necessary,  I  think  that  I  should,  even  in  these  cases, 
prefer  the  excision  of  the  polypus,  with  the  present  risk  of  hemor- 
rhage, to  the  somewhat  tardier,  but,  I  apprehend,  graver  dangers 
attendant  on  the  use  of  the  ligature. 

There  still  remain  a  few  varieties  of  uterine  disease,  concerning 
which  something  should  be  said,  before  we  pass  to  the  study  of 
those  malignant  aflcctions  of  the  womb,  that  constitute  the  most 
painfully  important  of  all  the  ailments  of  the  female  sexual  sys- 
tem. To  a  brief  notice  of  these  I  propose  devoting  the  remainder 
of  this  Lecture ;  and  first,  I  will  describe  a  very  rare  form  of  tumor 
of  the  womb,  which  resembles  in  its  character  what  has  been 
termed  the  Recurrent  Fibroid  tumor. 

In  the  eighth  volume  of  the  Transactions  of  the  Pathological 
Society-  there  are  recorded  by  Mr.  Hutchinson  the  particulars  of  a 
case  in  which  a  tumor  formed  within  the  uterine  cavity  of  a 
middle-aged  unmarried  woman,  and  gave  rise  to  floodings  large 
ill  amount  and  frequent  in  their  return.  At  the  end  of  twenty- 
three  months  an  attempt  was  made  to  remove  the  tumor,  which 
sprang  from  within  the  uterus  by  a  pedicle  as  thick  as  the  wrist, 
whence  a  mass  as  large  as  three  fists  projected  into  the  vagina, 

1  On  Diseases  of  Woinen,  &c.,  p.  281,  case  vii.  *  Page  287. 


RECURRENT    FIBROID     TUMOR.  2G9 

wlnle  the  uterus  itself  was  felt  as  large  as  a  cliild's  head  above  the 
} tubes.  The  soft  texture  of  the  tumor  prevented  it  from  being 
lirmly  fjrasped,  and  the  operation  was  discontinued  after  only  a 
com[»arativeIy  small  portion  of  the  mass  had  been  detached.  The 
bulk  of  the  tumor,  however,  subsequently  sloughed  awa}',  and  at 
the  end  of  a  month  no  trace  of  it  could  be  discovered,  nor  any 
enlargement  of  the  Avomb  detected.  For  the  next  three  months 
the  patient  continued  so  to  improve  that  it  was  hoped  a  perfect 
cure  had  been  effected;  but  at  the  end  of  six  months  the  growth 
was  reproduced,  though  it  had  not  quite  regained  its  former  size. 
A  second  operation  was  now  performed,  and  the  hand  introduced 
into  the  uterine  cavity  broke  down  the  tissue  of  the  tumor,  which 
it  was  found  possible  only  very  imperfectly  to  remove.  Temporary 
improvement  again  followed,  but  in  three  months  more  the  tumor 
had  grown  again,  and  was  attended  by  its  old  symptoms.  Attempts 
to  destroy  its  tissue  by  caustic  injections  caused  much  suficring  and 
did  little  good,  and  death  took  place  two  jears  and  ten  months 
after  the  commencement  of  the  patient's  illness. 

The  uterus  was  about  the  size  of  two  fists,  and  contained  a 
white  soft  growth,  attached  by  a  very  broad  base  to  the  fundus 
and  posterior  surface,  its  free  extremity  hanging  down  in  a  pol}'- 
poid  shape  close  to  the  os.  The  mucous  lining  of  the  cervix, 
though  congested,  was  healthy.  The  uterine  walls  were  much 
thickened  in  those  parts  to  which  the  tumor  had  no  attachment, 
but  were  thinned,  evidently  by  its  infiltration,  at  the  base  of  the 
growth. 

On  a  microscopic  examination  the  tumor  was  found  to  be  com- 
posed of  a  fibroid  tissue,  and  of  a  softer  material  made  up  of  round 
nuclear  bodies,  of  transparent  molecules,  and  of  some  fusitbrm 
cells.  Both  its  microscopic  character  as  well  as  the  history  of  the 
disease  seem  to  remove  the  tumor  from  the  class  of  malignant 
growths,  and  Mr.  Hutchinson's  own  interpretation  of  its  nature 
as  belonging  to  the  class  of  recurrent  fibroid  tumors  is  doubtless 
correct. 

In  his  paper  on  the  enucleation  of  fibrous  tumors,  Mr.  Hutch- 
inson refers  to  a  case  of  Dr.  Atlee's,  as  probal)ly  belonging  to  the 
same  category  with  the  one  just  related.  The  account  given  by 
Dr.  Atlee,^  however,  is  too  vague  to  enable  one  to  form  any  very 
accurate  judgment  of  the  structure  of  the  growth,  though  its  ri\\nd 
reproduction  after  removal  renders  his  opinion  in  the  highest  de- 
trrce  ])r()bable.  A  case  has  also  come  under  in}-  own  observation, 
that  belongs  to  the  same  class,  and  the  details  of  which,  as  will  be 
seen,  harmonize  very  closely  with  the  history  of  Mr.  llutclnnson's 
jiatient. 

A  young  unmarried  woman,  aged  twent3'-tlirec,  who  had  always 
had  good  health,  and  since  her  fourteenth  year  had  menstruated 
scantily,  but  without  pain,  every  three  weeks,  was  kicked  on  the 
lower  [)art  oi"  hei'  back  during  a  menstrual  jteriod  in  July,  18')2. 

'   Tronsndions  <>f  Atncrican  Medical  Associaiion,  vol.  vi,  p.  570,  ciisc  iii. 


270  RECURRENT    FIBROID    TUMOR. 

This  kick  was  followed. by  frequent  abundant  discharges  of  blood 
from  the  vagina,  and  towards  the  end  of  September  by  pain,  referred 
to  the  loins  and  hypogastrium,  and  by  a  sense  of  bearing  down, 
which,  however,  was  not  aggravated  by  moderate  exertion,  nor 
relieved  by  the  recumbent  posture. 

The  discharges,  which  had  reduced  her  to  a  state  of  great  weak- 
ness, were  described  at  the  time  of  her  admission  into  the  hospital 
on  October  1st,  1852,  as  being  habitually  offensive,  consisting 
sometimes  of  fluid  blood,  often  intermixed  with  large  coagula,  but 
being  at  other  times  greenish  and  watery. 

On  examination  the  os  uteri  was  found  widely  open,  and  a 
polypus,  apparently  of  the  size  of  a  pigeon's  egg,  protruded  through 
it,  Ijut  the  finger  could  not  be  passed  high  enough  up  to  reach 
the  point  of  its  insertion.  The  hooked  forceps  introduced  to 
draw  it  down,  tore  out  from  its  substance,  which  was  found  to 
be  remarkably  soft ;  but  a  portion  as  big  as  an  egg  having  been 
removed,  a  large  mass  was  still  left  behind  in  the  uterus.  No 
hemorrhage  followed  this  first  operation,  which  was  attempted  on 
October  4th;  on  the  10th,  the  ergot  of  rye  having  been  given  in 
the  interval  in  the  hope  of  forcing  the  tumor  lower  dc^wn,  the 
sound  passed  fou-r  and  a  half  inches,  and  the  finger  detected  a 
rough  mass,  not  unlike  placenta  or  very  old  clot,  firmly  adherent 
to  the  walls  of  the  uterus,  which  was  perfectly  movable  in  the 
pelvis. 

On  November  11th  a  second  attempt  was  made  to  remove  the 
tumor,  the  patient  having  in  the  interval  sutt'ered  nmch  fi-om 
hemorrhage,  and  having  also  experienced  considerable  pain.  The 
attempt,  however,  issued  in  the  removal  of  but  a  very  small  portion 
of  the  tumor,  whose  texture  again  broke  down,  while  its  attach- 
ment to  tlie  posterior  and  lower  part  of  the  uterus  was  too  broad 
to  allow  of  a  ligature  being  placed  around  it.  On  December  2()th, 
a  third  operation  was  attempted;  a  fourth  on  January  5th;  a  fifth 
on  February  21st;  and  a  sixth  on  March  8th;  the  growth  being 
partly  torn  away  by  the  fingers,  in  part  scraped  from  the  interior 
of  the  uterus  by  a  blunt  knife,  whose  blade  was  fixed  at  right 
angles  to  its  handle.  After  each  operation  masses  of  the  tumor 
came  away,  and  it  was  estimated  that  altogether  the  quantity 
removed  in  and  after  the  several  operations  amounted  to  about 
six  ounces.  On  April  11th,  the  sound  still  entered  three  and  a 
half  inches,  showing  that  thongh  the  size  of  the  uterus  was  dimin- 
ished, it  had  not  yet  returned  to  its  natural  dimensions ;  while, 
though  the  os  was  closed,  so  that  the  exact  state  of  things  could 
not  be  nscertained,  I  yet  feared  the  reproduction  of  tlie  tumor,  for 
I  had  been  struck  by  the  circumstance  that  in  spite  of  its  laceration 
and  of  the  forcible  avulsion  of  portions  of  it  at  each  operation,  it 
yet,  on  ever}^  repetition  of  the  proceeding,  presented  the  same 
smooth  surface. 

Microscopic  examination  of  the  portions  of  the  tumor  showed 
its  texture  to  be  made  up  of  imperfectly  formed  fibres,  and  of  an 


RECURRENT     FIBROID     TUMOR.  271 

ao;greg-ation  of  cells  resembling  those  of  inflammatory  lympli,  or 
granulation  cells. 

In  April  the  patient  left  the  hospital,  but  at  the  end  of  June  she 
had  a  most  alarming  hemorrhage,  during  which  large  portions  of 
the  tumor  were  discharged,  intermixed  with  coagula.  At  the 
beginning  of  August  she  was  readmitted,  and  the  eidarged  uterus 
was  now  felt  distinctly  over  the  pubes,  while  on  a  vaginal  exanu- 
nation  its  lower  segment  was  felt  much  distended.  The  os  uteri 
was  dilated  with  sponge  tents,  and  as  much  of  the  tumor  as  could 
be  removed  in  fragments  was  extracted,  though  the  quantity  did 
not  much  exceed  six  drachms.  The  muriated  tincture  of  iron  was 
now  injected  into  the  broken-down  issue,  in  the  hopes  of  thus 
ex[)editing  its  destruction,  and  this  was  repeated  thrice  between 
that  time  and  the  17th  of  October.  The  patient,  however,  dreaded 
these  injections  very  much  on  account  of  the  severe  pain  which 
they  occasioned ;  while  chloroform  produced  so  much  and  such 
abiding  sickness  and  (Repression,  that  it  was  not  possible  to  have 
recourse  to  its  use. 

In  December,  1853,  an  attack  of  hemorrhage  was  accompanied 
by  the  expulsion  of  six  ounces  of  the  tumor;  and  on  the  loth  of 
that  month  a  large  portion  was  removed ;  and  on  February  20th, 
1854,  a  ninth  ancl  last  operation  was  performed.  The  suflering 
caused  by  each  operation,  not  so  much  at  the  moment  of  its  per- 
formance as  subsequently,  when  much  al)dominal  tenderness  was 
always  experienced,  and  a  great  degree  of  constitutional  dis- 
turbance was  produced,  coupled  with  the  necessarily  incomi)lete 
character  of  each  operation,  and  the  extreme  rapidity  with  which 
the  growth  was  reproduced,  led  me  from  this  time  to  abstain  from 
all  interference.  It  would  be  tedious  to  relate  minutely  the  sub- 
sequent history  of  the  patient,  wlio,  in  the  autumn  of  1857,  was 
still  able  to  follow  a  sedentary  occupation,  and  to  walk  half  a  mile 
in  order  to  show  herself  to  me  at  the  hospital.  She  had  had  many 
attacks  of  profuse  hemorrhage,  one  of  which,  in  May,  1856,  very 
neaiJy  proved  fatal,  and  was  followed  for  weeks  by  alarming  de- 
])ression,  with  severe  abdominal  pain,  which  was  kept  under  only 
by  large  doses  of  morphia;  and  by  profuse,  extremely  ottensive 
watery  discharges.  The  outline  of  the  abdominal  tumor,  too, 
could  be  felt  above  the  umbilicus,  the  abdomen  measuring  at  that 
point  thirty-two  and  a  half  inches;  while  per  vaginam  a  lobulated 
soft  growth  extended  through  the  widely-dilated  mouth  of  the 
womb.  In  spite  of  the  decided  increase  of  the  abdominal  tumor, 
however,  the  patient's  condition  steadily  improved,  after  her  re- 
covery from  the  hemonhage  in  May,  1850,  since  which  time  no 
considerable  loss  of  blood  occurred,  though  the  abdomen  remained 
extremely  tender;  and  the  patient,  in  spite  of  added  strength, 
remained  pale  as  a  marble  statue. 

On  Decend)er  20,  1857,  she  re-entered  the  hos[tital  for  the  last 
time,  not  sutfering  indeed  from  any  return  of  her  uterine  symp- 
toms, but  from  pain,  which  she  conceived  to  be  rheumatic,  in  her 
neck,  and  from  cough  brought  on  by  exposure  to  cold  a  week 


272  RECURRENT    EIBROID     TUMOR. 

before.  Some  swelling  was  perceptible  on  the  right  side  of  the 
cervical  vertebrae,  and  light  was  thrown  on  its  probable  nature  in 
the  course  of  a  few  days  by  the  occurrence  of  numbness  of  the 
right  arm  and  leg,  and  difficulty  in  moving  them.  l!^ext,  power 
over  the  left  arm  and  leg  became  similarly  impaired ;  and  the 
urine  was  voided  involuntarily  as  well  as  unconsciously.  The 
respiration,  too,  was  labored  to  an  extent  which  auscultation  did 
not  account  for;  and  the  strength  daily  declined,  though  without 
suffering,  and  death  took  place  qnietly  on  the  3d  of  January,  1858  ; 
nearly  six  and  a  quarter  years  from  the  commencement  of  the 
patient's  illness. 

The  following  account  of  the  appearances  after  death  is  from 
the  notes  of  my  friend  and  colleague,  Mr.  Callender.  The  rarity 
of  the  case  furnishes  my  excuse  for  relating  it  in  such  detail:  On 
opening  the  sac  of  the  peritoneum,  a  large  oval  tumor,  in  front  of 
which  lay  several  coils  of  small  intestine,  was  seen  occupying  the 
left  iliac  fossa,  and  extending  upwards  to  about  the  level  of  the 
middle  of  the  left  kidney.  It  was  invested  by  a  thin  transparent 
membrane,  which  di})ped  in  between  the  convolutions  that  divided 
the  tumor  into  lobes  of  unequal  size. 

The  tumor  was  of  a  white  or  pale  straw  color,  slightly  vascu- 
lar, a  few  large  bloodvessels  ramifying  over  its  surface.  It  grew 
from  the  posterior  wall  of  the  uterus,  to  which  it  was  connected 
by  means  of  a  broad  base,  two  inches  and  a  half  thick,  by  one 
and  a  half  in  length.  The  tumor  itseli'  measured  five  and  a  half 
inches  in  breadth.  The  uterus  occupied  the  entire  pelvis,  and 
rose  to  some  height  above  the  level  of  its  brim.  Its  walls  were 
only  a  quarter  of  an  inch  in  thickness,  and  the  os  uteri  was  so  di- 
lated by  a  tumor  which  projected  through  it,  that  it  was  impossible 
to  determine  exactly  where  the  uterus  ceased  and  the  vagina  be- 
gan. -  The  uterus  thus  attenuated  was  stretched  over  a  large  tumor 
which  occupied  its  interior.  This  tumor  was  attached  by  a  broad 
base  to  the  posterior  uterine  wall,  where  it  was  continuous  with 
the  growth  which  projected  into  the  iliac  fossa,  while  anteriorly 
and  "at  the  sides  it  was  perfectly  free. 

Independently  of  this,  a  few  isolated  nodules  Avere  connected 
with  the  right  side  of  the  uterus,  and  projected  upon  its  inner 
aspect,  involving  the  mucous  and  submucous  coat.  The  lobed 
surface  of  the  tumor  was  free  from  any  irregularities  such  as 
might  have  been  expected  from  the  previous  operations.  The 
lobes  were  more  marked  and  more  irregular  on  the  anterior  and 
lower  portion  of  the  tumor  than  elsewhere.  It  measured  seven 
and  a  half  inches  in  length,  by  five  inches  in  breadth.  These 
tumors  presented  throughout  the  ordinary  characters  of  recurrent 
fibroid  growths,  being  composed  of  narrow,  elongated,  caudate, 
and  oat-t<hapcd  nucleated  cells,  with  some  detached  nuclei,  and 
granular  matter. 

The  lumbar  glands  were  the  seat  of  a  similar  deposit;  and  no- 
dules of  a  similar  kind  were  imbedded  in  the  lungs,  and  connected 
with  the  parietal  layer  of  the  pericardium.     A  mass  of  the  same 


FATTY    TUMORS    OF    THE     UTERUS.  273 

kind  was  seen  projecting  from  tlie  body  of  tlie  sixth  cervical  ver- 
tebra, and  the  same  deposit  l)eing  infiltrated  into  the  sn1)stanceof 
the  bone  had  expanded  it,  both  anteriorly  and  posteriorly,  com- 
pressing the  anterior  colnmns  of  the  spinal  cord,  and  producing 
the  symptoms  which  at  length  proved  fatal.* 

I  have  related  this  case  at  length  on  account  of  its  rarity,  and 
because  its  duration  of  more  than  six  years  brings  into  stronger 
prominence,  than  did  the  history  of  Mr.  Hutchinson's  patient,  the 
dilierences  between  this  kind  of  growth  and  those  of  a  truly  malig- 
nant character.  No  cancer-cells  were  detected  in  the  uterine  tumor 
either  during  the  patient's  life,  or  when  the  parts  were  removed 
after  her  death;  and  though  the  nodules  in  the  lungs  were  thought 
by  some  who  examined  their  structure  to  contain  cells  resembling 
those  of  ordinary  scirrhus,  yet  Mr.  Callender  did  not  discover  any, 
while  every  one  agreed  as  to  the  abundance  of  fibroid  material. 

I  know  of  no  other  cases  resembling  these.  Our  experience  is 
at  present  too  small  to  warrant  our  arriving  at  very  positive  con- 
clusions respecting  the  disease  which  they  illustrate.  It  may, 
however,  be  doubted  whether  our  wiser  course  is  not  to  let  the 
disease  alone;  for  while  its  complete  removal  seems  impossible, 
its  partial  extirpation  appears  to  be  followed  by  an  increased 
rapidity  in  its  reproduction. 

Two  instances  oi  Fatty  Tumors  of  the  uterus  are  reported  in 
the  German  medical  journals;  and  though  nothing  of  the  kind 
has  ever  come  nnder  my  notice,  it  might  seem  an  omission  if  I 
failed  to  refer  to  them. 

The  patients  in  whom  this  growth  was  observed  were  of  the 
respective  ages  of  fifty  and  fitty-three.-  The  former  of  these 
women,  after  suffering  for  eleven  years  from  leucorrhoea,  expelled 
from  the  vagina  a  tumor  the  size  of  the  fist,  which  was  ascertained 
to  be  niade  up  of  fat,  closely  resembling  cholesterine,  though  not 
quite  identical  with  it.  In  the  other  case  the  tumor,  which  was 
of  the  size  of  a  child's  head,  projected  beyond  the  external  parts, 
but' was  connected  by  a  pedicle  three  fingers  broad  with  the  wliole 
margin  of  the  os  uteri.  It  was  removed  by  ligature,  and  the 
patient,  who  had  been  subject  to  menorrhagia  for  a  year  previ- 
ously, recovered.  The  tumor,  which  weighed  three  pounds  and 
a  half,  is  said  to  have  been  an  ordinary  fatty  tumor,  having  an  in- 
vestment of  dense  cellular  tissue,  septa  of  which  dipped  down 
into  its  substance.  The  patient  in  the  first  case  continued  alter 
the  expulsion  of  the  tumor  liable  to  periodical  discharges  of  ver}' 
offensive  slimy,  watery  fluid,  in  which  were  now  and  then  small 
flat  masses  similar  to  the  larger  substance.  The  state  of  the  cer- 
vix was  quite  natural,  and  I  suppose  that  in  this  case  the  deposit 
of  fat  had  taken  place  upon  the  free  surface  of  the  diseased  mucous 

1  This  cfise  is  described  at  length  by  Mr.  Callender,  in  vol.  ix  of  the  Transactions 
of  the  Patholofflral  Society,  p.  327. 

2  The  e:isi'.«  are  related  by  Dr.  W.  Biiseh,  in  Matter's  Arc/iiv,  1851,  p.  358,  Dr. 
8eegcr,  in  Murtctnb.  Zeitsc/ir,  vol.  v,  1852,  and  tjchniidt's  Julirb.,  Dec,  1852,  p.  835. 

18 


274  FATTY    TUMORS     OF    THE    UTERUS. 

membrane  of  the  womb,  and  had  by  degrees  accumulated  in  the 
cavity  of  the  organ  until  it  stimulated  its  muscular  fibres  to  con- 
tract upon  and  expel  it. 

In  conclusion,  I  will  add  a  few  words  concerning  tubercular 
deposit  in  the  uterus,  though  it  ought  not,  perhaps,  in  strict  pro- 
priety, to  be  noticed  here,  but  should  rather  be  referred  to  a  sepa- 
rate category.  Convenience,  however,  may  be  allowed  to  overrule 
strictly  scientific  arrangement.  It  happens  occasionally  that  on 
examining  the  uterus,  although  its  exterior  may  appear  quite 
healthy,  and  the  canal  of  the  cervix  also  be  free  Irom  disease,  the 
whole  of  its  cavity  is  found  occupied  by  a  matter  of  a  dirty  yellow 
color,  closely  resembling  both  in  its  aspect  and  its  consistence  the 
substance  of  a  tubercular  bronchial  gland  when  just  beginning  to 
soften.  This  deposit  is  generally  about  an  eighth  of  an  inch  in 
thickness,  is  easily  scraped  away  with  the  back  of  the  scalpel;  but 
on  its  removal  it  is  found  that  all  trace  of  the  lining  of  the  uterus 
has  disappeared  too,  or  if  anywhere  a  portion  of  it  remains,  that 
is  seen  to  be  opa(^ue,  more  vascular  than  natural,  and  to  present 
beneath  it  small  yellow  spots,  looking  like  distinct  tubercular 
deposits,  which,  in  fact,  they  have  been  ascertained  to  be  by  care- 
ful microscopic  examination.  In  cases  where  the  disease  is  only 
beginning,  the  separate  yellow  dc}>osits  in  tlie  mucous  membrane 
are  alone  apparent,  while  when  the  disease  is  far  advanced  (and  it 
was  so  in  the  two  cases  which  came  under  my  own  observation), 
not  only  is  the  mucous  membrane  completely  destroyed,  but  the 
deposit  encroaches  on  the  substance  of  the  womb,  its  cavity  is 
enlarged  by  the  abundance  of  the  morbid  substance,  and  its  v/alls 
are  thickened;  changes  that  in  some  instances  have  been  known 
to  occur  to  a  very  considerable  extent. 

In  the  great  majority  of  cases  the  tubercular  deposit  does  not 
extend  beyond  the  cavity  of  the  uterus,  though  sometimes  a  similar 
matter  is  found  distending  the  Fallopian  tubes,  and  tubercular 
degeneration  of  the  ovaries  now  and  then  coexists  with  the  disease 
of  the  interior  of  the  womb.  Either  of  these  occurrences  is,  how- 
ever, more  frequent  than  the  extension  of  the  disease  to  the  cer- 
vical canal;  and  Rokitansky'  states  that  it  scarcely  ever  appears 
there  as  a  primary  deposit.  Occasionally  one  sees  in  the  living 
subject,  on  the  surface  of  one  or  both  lips  of  the  uterus,  deposits 
of  a  yellow  color,  of  the  size  of  a  split  pea,  or  smaller,  having 
altogether  the  appearance  of  small  deposits  of  yellow  tubercle, 
and  which  on  being  pricked  give  issue  to  a  small  quantity  of 
matter  of  the  consistence  of  pus,  or  rather  firmer,  and  having  a 
granular  appearance  under  the  microscope.  These  deposits  have 
been  alleged  to  be  tuberculous;  and  the  high  authority  of  the  late 
Professor  Kiwisch^  may  be  adduced  in  support  of  that  opinion. 
I  am  familiar  with  the  appearance,  but  am  not  altogether  con- 
vinced of  its  tuberculous  character,  and  am  rather  inclined  to  con- 

1  Pnihol  Anatomic,  3d  ed.,  1861,  vol.  iii,  p.  498. 
'  Op.  cit.  vol.  i,  p.  558. 


TUBERCLE  OF  THE  UTERUS.  275 

sider  it  as  cine  to  hypertrophy  of  some  of  the  ISTabothian  follicles, 
with  obliteration  of  tlieir  orifices  and  alteration  of  their  contents. 
At  any  rate,  thoug-h  small  slightly  excavated  ulcers  are  now  and 
then  left  behind,  I  have  never  been  able  to  trace  any  connection 
between  this  appearance  and  any  form  of  destructive  ulceration 
of  the  cervix. 

The  disease  seems  to  be  always  secondary  to  tubercular  deposit 
elsewhere,  and  even  then  to  be  of  rare  occurrence,  though  perhaps 
less  so  than  it  was  believed  to  be  by  Louis,^  who  did  not  estimate 
its  frequency  higher  than  one  and  a  half  per  cent,  of  all  cases  of 
tubercle  in  general.  M.  Kiwisch-  states,  that  at  Prague  it  was  met 
with  once  in  every  forty  cases,  or,  in  other  words,  with  a  frequency 
of  two  and  a  half  per  cent. ;  and  I  know  of  no  other  statistics 
bearing  on  the  subject. 

The  following  table  deduced  from  data  furnished  by  Kiwisch 
and  a  recent  very  painstaking  writer  on  the  subject,  Dr.  Geil,^ 
furnishes  some  information  not  without  its  value. 

Tubercular  deposit  in  the  uterus  was  met  with — 

In  6  subjects  between  10  and  20  years. 

"22  "  "  20  —  30  " 

"15  "  "  30  —  40  " 

"10  "  "  40  —  50  " 

"    7  "  "  50  —  60  " 

"    6  "  "  GO  —  70  " 

"    2  "  "  70  —  80  " 

Total,  08 

In  forty-five  of  the  cases  collected  by  Dr.  Geil,  the  seat  of  the 
aflection  is  distinguished — 

Uterus  alone  affected, 1  case 

"      and  fnbp9  /  with  affection  of  peritoneum, .  19  cases 

'  \  without         "  "  .  12     " 

Uterus,  tubes,       /  in  form  of  an  aphthous  process,  2  cases 
and  vagina,  .     \          "         true  tuberculous  ulcers,  1  case 

Tubes  alone  affected, 8  cases 

Eight  tube  alone, 2     "■ 

Total,  45 

Amenorrhoea  or  dysmenorrhoea,  often  associated  with  leucor- 
rhocal  discharges,  are  the  s/jmptoms  which  are  ordinarily  observed 
in  connection  with  uterine  tuberculosis.  Pain  appears  to  be  an 
exceptional  occurrence,  and  when  present,  neither  to  be  an  early 
8ym];)tom,  nor  commonly  to  attain  to  any  great  severity,  though 
now  and  then,  as  in  the  interesting  case  which  came  under  my  own 

^  Recherchcn  sur  la  Phthisic,  2d  ed.,  Paris,  1834,  p.  142. 

2  Op.  cit.,  p.  559. 

3  In  an  inaugural  dissertation,  published  at  Erlangen  in  1851,  and  of  which  an 
abstract  is  given  in  Schmidt's  Jahrhiirher,  March,  1852,  ]>.  324.  Some  additional 
cases,  whirl),  however,  throw  no  fresh  light  on  the  subject,  will  be  found  in  the 
abstract  of  a  paper  by  M.  Crocq  in  Archives  de  Med.,  1800,  vol.  ii,  ji.  215;  and  in 
another  by  M.  Paulsen,  in  Schmidt's  Jahrbiicher,  1852,  vol.  80,  p.  222. 


276  CANCER     OF    THE    UTERUS. 

notice,  and  which  was  described  by  Mr.  Tomlinson  of  Burton-on- 
Trent,  at  a  meeting  of  the  Obstetrical  Society,  pain  may  become 
very  severe.  In  many  instances  no  symptoms  have  attended  the 
aftection  during  life,  while  those  which  have  jost  been  enumerated 
present,  as  I  scarcely  need  to  say,  nothing  pathognomonic  of  this 
peculiar  disease.  Indeed,  if  we  bear  in  mind  that  tuberculous 
affections  of  the  womb  appear  to  be  almost  always  secondary  to 
extensive  deposit  of  tubercle  in  other  organs,  we  are  led  to  the 
practical  inference  that,  in  cases  where  phthisical  symptoms  are 
present,  there  is  every  reason  for  interfering  as  little  as  possible  for 
the  removal  of  amenorrhoea,  or  other  irregularities  of  the  menstrual 
function,  and  especially  for  abstaining  from  much  local  treatment 
of  any  other  uterine  ailment  that  may  occur.^ 


LECTURE   XIX. 

MALIGNANT  OE  CANCEROUS  DISEASES  OF  THE  UTERUS. 

Hopelessness  of  the  subject,  but  importance  of  questions  involved  itiits  study  ;  erro- 
neous opinions  formerly  held  concerning  it. 

Definition  of  Cancer  ;  its  varieties.  Scirrhus  extremely  rare  ;  its  anatomical 
characters. 

Medullary  Cancer;  its  nature,  mode  of  occurrence  of  ulceration,  Its  rapid  progress; 
abortive  attempts  at  cure,  and  advance  of  the  disease.  Hypertrophy  of  uterus 
in  its  course  ;  changes  in  its  walls  ;  its  interior  ;  on  its  surface.  Extension  of 
disease  to  vagina  and  bladder.  Exceptional  cases;  cancer  of  body  of  uterus; 
cancerous  polypi.     Alveolar  cancer. 

Epithelial  Cancer  ;  its  general  characters;  its  relation  to  medullary  cancer  ;  essen- 
tial identity  with  Cauliflower  Excrescence. 

Ulcers  of  the  os  uteri ;  the  so-called  Tuberculous  Ulcer  ;  Corroding  Ulcer. 

Frequency  of  secondary  afiections  in  cases  of  uterine  cancer. 

In  the  study  of  the  diseases  which  have  hitherto  engaged  our 
attention,  we  have  never  entirely  lost  a  sense  of  hopefulness. 
Either  medicine  might  cure  the  ailment,  or  surgery  might  remove 

1  Twice  have  I  met  with  symptoms  of  disease  of  the  womb  which  I  regarded 
as  tuberculous,  bvit  had  no  opportunity  of  verifjnng  my  diagnosis  by  a  post-mortem 
examination.  The  patients  in  these  cases  were  aged  35  and  53  years  respectively. 
The  younger  had  given  birth  to  children  ;  the  elder  had  not  married  until  late  in 
life,  and  had  never  been  pregnant.  Theyounger  patient  was  in  a  state  of  advanced 
phthisis,  with  cavities  in  the  lui)gs;  the  elder  had  had  symptoms  of  consumptive 
disease  in  early  life,  and  percussion  was  dull  and  respiration  feeble  in  the  left 
infra-clavicular  region.  In  both  patients  leucorrhceahad  preceded  any  other  local 
symptom  ;  in  both  this  discharge  came  from  the  interior  of  the  uterus,  was  thick, 
tenacious,  yellowish  in  one  case,  greenish  in  the  other ;  had  a  peculiar  faint  smell, 
but  not  the  offensive  odor  of  cancer.  In  neither  was  there  any  hemorrhage;  and 
menstruation,  which  still  continued  in  the  younger  patient,  had  in  her  become  ex- 
tremely scanty.  Pain  had  come  on  gradually,  had  increased  slowly,  but  amounted 
at  last  after  the  lapse  of  a  year,  to  intolerable  ceaseless  anguish.  There  vv^as  some 
tenderness  over  the  uterus,  which  was  somewhat  enlarged  ;  but  there  was  no  hard- 
ness about  the  cervix — no  unhealthy  condition,  either  to  the  touch  or  eye,  about 
the  mouth  of  the  womb.  The  symptoms  were  not  those  of  cancer  of  the  body  of 
the  uterus,  but  they  resembled  not  a  little  those  described  by  Mr.  Tomlinson.  I 
do  not  know  how  long  either  of  these  patients  lived,  but  I  know  that  it  was  more 
than  two  years. 


CANCER    OF    THE    UTERUS.  277 

« 

it;  or  at  the  very  worst,  so  much  might  be  done  to  retard  its  prog- 
ress, and  to  alleviate  the  siifFerings  Avliich  it  occasioned,  that  lite 
was  in  many  instances  but  little,  if  at  all  shortened  ;  was  sometimes 
even  scarcely  embittered  b}'  its  presence. 

In  passing  now,  however,  to  the  investigation  of  the  malignant 
diseases  of  the  womb,  of  cancer  and  its  allied  disorders,  we  shall 
find  but  few  of  those  mitiii-atins:  circumstances  which  lessen  the 
darkness  of  the  picture  in  the  case  of  many  other  incurable  affec- 
tions. Pain,  often  exceeding  in  intensitj-  all  that  can  be  imagined 
as  most  intolerable,  attended  by  accidents  which  render  the  sufferer 
most  loathsome  to  herself  and  to  those  whom  strong  affection  still 
gathers  round  her  bed ;  the  general  health  broken  down  by  the 
action  of  the  same  poison  as  produces  the  local  suffering,  and  all 
tending  surely,  swiftly,  to  a  fatal  issufe,  wliich  skill  cannot  avert, 
from  which  it  can  scarcely  take  away  its  bitterest  anguish :  such 
are  the  features  in  the  picture  which  I  must  now  call  on  you  to 
contemplate,  and  that  not  hurriedly,  nor  for  a  moment,  but  most 
carefully  and  deliberately,  and  in  all  its  various  aspects. 

There  are  indeed  many  reasons  which  prevent  our  passing  over 
the  subject  of  uterine  cancer  (as  we  might  be  glad  to  do)  with  but 
a  passing  notice.  The  frequency  of  the  disease  forbids  it,  for 
scarcely  any  age  is  free  from  its  attack,  while  it  is  doubtful  whether 
any  other  form  of  organic  affection  of  the  womb  is  met  with  so 
often,  and  it  is  certain  that  there  is  no  other  so  fatal.  The  dread 
most  naturally  felt,  lest  this  symptom  or  that  symptom  should 
portend  the  outset  or  imply  the  existence  of  cancer,  forbids  it ;  for 
we  are  called  on  over  and  over  again  to  remove  the  ai)prehen- 
sions  of  women  whose  fears  have  been  excited  by  some  uterine 
ailment,  perhaps  of  no  great  moment,  but  out  of  which  they  have 
shaped  to  their  affrighted  fancies  all  the  hideous  featui'es  of  an 
incurable,  an  almost  unbearable  disease.  Need  I  say,  then,  how 
much  it  imports  that  we  should  be  able  to  remove  such  a})prehen- 
sions  when  causeless,  not  by  holding  out  vague  hopes  or  uncer- 
tain expectations,  but  by  positive  assurances  founded  on  large 
and  accurate  experience,  and,  as  far  as  may  be,  on  certain  knowl- 
edge ? 

To  those  practitioners  and  writers,  both  English  and  foreign, 
who  have  taken  the  most  active  part  in  the  study  of  the  inflamma- 
tory affections  of  the  neck  of  the  womb,  and  whose  investigations 
have  led  them  (as  some  believe,  and  I  confess  m3-self  tohe  of  that 
number)  to  an  exaggerated  estimate  both  of  their  frequency  and 
of  their  importance,  we  yet  owe  a  debt  of  gratitude  for  the  light 
which  they  have  thrown  on  this  disease,  which  outweighs  many 
overstatements  and  cancels  many  errors.  Cancer  of  the  uterus 
used  before  their  time  to  be  described  as  a  disease  slow  in  prog- 
ress, continuing  in  its  first  quiescent  stage  of  scirrhus  not  only 
for  months,  but  for  years,  and  then,  excited  by  one  knows  not 
what  cause  to  activity,  passing  into  the  state  of  ulcerated  carcinoma, 
and  thus  at  its  close  quickly  destroying  the  patient.  It  sufficed, 
then,  for  the  neck  of  the  wond)  to  be  hard  and  painful,  and  some- 


278  VARIETIES    OF    CANCER.  ^ 

what  enlarged,  for  the  suspicion  of  malignant  disease  to  be  enter- 
tained, and  for  years  of  causeless  anxiety  to  be  entailed  upon  the 
patient.  Such  and  such  like  were  the  results  which  followed  from 
confounding  the  consequences  of  inflammation  and  of  kindred 
processes,  with  the  changes  which  the  deposit  of  the  elements  of 
cancer  brings  about  in  the  aifected  part. 

It  is  scarcely  necessary  to  define  eancer,  but  if  some  definition 
must  be  adopted,  I  know  of  none  better  than  Mliller's  •}  "  Those 
growths  may  be  termed  cancerous  which  destroy  the  natural  struc- 
ture of  all  tissues,  which  are  constitutional  from  their  very  com- 
mencement, or  become  so  in  the  natural  process  of  their  develop- 
ment, and  which  when  once  they  have  infected  the  constitution, 
if  extirpated,  invariably  return,  and  conduct  the  person  who  is 
affected  by  them  to  inevitable  destruction."  Taking  this  defini- 
tion, however,  as,  on  the  whole,  the  best  that  can  be  given,  we 
must  still  bear  in  mind  that  morbid  anatomy  and  chemical  research 
have  both,  within  the  five  and  twenty  years  that  have  passed  since 
it  was  framed,  tended  to  show  great  diversities  between  the  dilfor- 
ent  forms  of  carcinoma,  and  to  show  also  that  many  of  those  which 
aflect  the  womb  are  local  in  their  origin  and  continue  so  through 
much  of  their  progress  ;  and  that  probably  if  we  could  always  dis- 
cover the  existence  of  the  disease  early,  we  often  need  not  despair 
of  its  cure. 

No  form  of  carcinoma  seems  to  be  peculiar  to  the  uterus,  though 
they  do  not  all  occur  with  anything  like  the  same  frequency. 
Fungoid  or  medullary  carcinoma  is  by  far  the  most  common  ;  next 
in  frequency  maybe  classed  the  epithelial  varieties  of  the  disease, 
if,  indeed,  it  be  not  more  correct,  as  some  men  of  high  authority 
believe,  to  refer  them  to  a  separate  category  distinct  from  genuine 
cancer.  Next  to  them,  but  divided  by  an  interval  which  widens 
in  exact  proportion  as  fresh  evidence  is  brought  to  bear  on  the 
subject,  may  be  classed  scirrhus,  or  hard  cancer;  while  almost  as 
rare,  or,  perhaps  even  more  uncommon,  stands  the  colloid,  or 
alveolar  variety  of  the  disease. 

The  only  attempt  with  which  I  am  acquainted  at  a  numerical 
estimate  of  the  comparative  frequency  of  scirrJnts,  or  hard  cancer^ 
and  other  varieties  of  malignant  disease  of  the  womb,  is  tlie  state- 
ment by  the  late  f*rofessor  Kiwisch,^  that  about  three  of  every  ten 
cases  of  cancer  of  the  womb  are  scirrhous.  This  estimate,  however, 
in  all  probability  much  overrates  the  frequency  of  scirrhus  ;  and  I 
cannot  but  think  that  many  instances  of  firm  medullary  cancer 
have  been  regarded  as  scirrhus,  and  this  not  only  by  less  compe- 
tent observers,  but  even  by  Kiwisch  himself  He  goes  on  to  say 
"  that  with  the  commencement  of  the  softening  of  fibrous  carci- 
noma, the  peculiar  characters  of  the  growth  progressively  disap- 
pear ;  it  grows  like  medullary  cancer,  becomes  more  vascular,  and 
is  easily  broken  down  ;  contains  a  pultaceous,  brain-like  substance, 

'  0?i  Cancer,  &c.,  English  translation,  8 vo.,  London,  1840,  p.  28. 
2  Op.  cit,  vol.  i,  p.  518. 


SCIRRHOUS    CANCER.  279 

and  the  ulcer  which  forms  upon  it  presents  precisely  the  same  ex- 
ternal appearance,  and  the  same  characters  as  those  which  result 
from  the  breaking  down  of  medullary  cancer." 

The  great  authority  of  Rokitansky'  may  further  be  adduced  in 
support  of  the  opinion  that  "fibrous  cancer  is  of  extreme  rarity;" 
while,  on  the  other  hand,  "medullary  carcinoma  occurs  with  the 
greatest  frequency."  To  say  after  this  that  I  have  not  met  on  a 
post-mortem  examination  with  any  example  of  genuine  scirrhus  of 
the  uterus,  considering  how  few  comparatively  are  my  o[>portunities 
for  observation  after  death,  may  seem  almost  an  idle  impertinence. 
It  is  more  to  the  purpose,  however,  to  add  that  my  friend  Mr. 
Paget  informs  me  that  he  has  not  met  w'itli  any  instance  of  it,  while 
any  one  who  carefully  examines  the  preparations  in  our  anatomical 
museums  will  find  that  this  disease,  once  said  to  be  so  common,  is 
in  reality  but  seldom  met  with.  It  is  perhaps  not  irrelevant  to 
mention,  that  of  one  hundred  and  seventy  cases  of  uterine  cancer 
of  which  I  have  a  record,  the  disease  appeared  from  an  examination 
during  the  patient's  life  to  be  of  the  medullary  kind  in  a  hundred 
and  thirty-seven,  epithelial  in  tw^enty-eiglit,  epithelial  and  fungoid 
combined  in  two,  and  colloid  in  two,  while  in  only  one  instance 
did  I  recognize  the  character  of  scirrhus,  though  I  have  seen  some 
cases  of  alleged  scirrhus  in  which  the  history  of  the  patient  and 
the  result  of  long-continued  observation,  plainly  showed  the  name 
to  have  been  misapplied,  and  the  enlargement  and  induration  to 
be  due  to  causes  of  a  perfectly  innocent  kind.^ 

In  spite  of  ditferences  on  other  points,  all  observers  are  agreed 
that  the  neck  of  the  womb,  or  rather  that  part  of  it  which  projects 
into  the  vagina,  the  portio  vaginalis,  is  the  point  at  which  cancer 
generally  commences,  and  to  which,  for  a  season,  it  is  confined.  Its 
mode  of  commencement  differs,  according  as  the  disease  belongs 
to  the  epithelial  or  to  the  medullary  form.  In  the  first  case,  the 
papilhc  of  the  os  uteri  seem  to  be  the  point  of  departure  of  the 
evil,  and  a  large,  gi-anular,  sprouting  outgrow'th  not  infrequently 
projects  into  the  vagina,  while  still  the  subjacent  tissue  is  but  little 
involved.  In  the  second  case,  the  morbid  deposit  takes  place  in 
the  substance  of  the  part,  enlarging,  but  thickening  far  more  than 
lengthening  it,  increasing  the  size  of  the  lips  of  the  uterus,  ren- 
dering them  hard  and  tense,  though  still  not  without  a  certain 
elasticity,  and  at  the  same  time  irregular  and  nodulated  ;  while  as 
they  enlarge  they  usually  gape,  and  leave  the  mouth  of  the  womb 
and  the  lower  part  of  its  cervical  canal  more  widely  open  than  in 
a  state  of  health. 

On  making  an  incision  into  the  parts  which  have  thus  lost  their 
ordinary  characters,  the  place  of  the  natural  structure  of  the  uterus 

1  P(iihit\t>(j\srlie  Ajintnmie,  vol.  iii,  p.  SriO. 

2  I  am  well  aware  that  this  superfitial  kind  of  oxaniinntinn  which  nlono  is  prao- 
tioftlilf  during  lifo,  is  almost  valueless  towards  the  decision  of  a  question  concerning 
which  much  difference  of  opinion  exists,  even  among  the  most  niorl)i(l  anatomists, 
such  as  Virchow  and  lioUitansUy.  The  rarity  of  true  scirrhus  is  the  one  point 
concerning  wliich  all  are  agreed. 


280  ULCERATION    OF 

is  found  to  be  more  or  less  occupied  by  a  white,  firm,  semi-trans- 
parent deposit,  which  in  some  parts  seems  infiltrated  into  the 
proper  tissue  of  the  womb,  in  others  has  entirely  taken  its  place. 
This  deposit  is  always  more  abundant  near  the  mucous  surface  of 
the  organ  than  towards  its  outer  vjaW ;  and  a  thin  layer  of  mus- 
cular substance  may  often  be  detected  beneath  the  peritoneal  in- 
vestment of  the  uterus,  even  when  the  conversion  of  its  tissues 
into  cancerous  structure  has  been  most  complete. 

It  is  very  seldom  that  after  death  one  finds  notliing  more  than 
this  substitution  of  cancerous  deposit  for  the  proper  tissue  of  the 
womb.  In  the  great  majority  of  cases  softening  takes  place,  even 
while  the  part  involved  is  but  a  comparatively  small  portion  of  the 
womb ;  softening  is  soon  followed  by  death  of  the  mucous  mem- 
brane of  the  OS  uteri;  an  ulcer  forms,  a  ragged  uneven  sore,  with 
raised,  irregular,  hardened  edges;  and  a  dirty  putrilage  covering 
its  uneven  surface,  takes  the  place  of  the  smooth  but  enlarged  lips 
of  the  organ.  Or,  if  the  disease  go  on  still  lurther,  the  \]\)S,  of  the 
womb  and  its  cervix  are  altogether  destroyed,  and  a  soft,  dirty 
white  flocculent  substance  covers  the  uneven,  granular,  and  hard- 
ened substance,  which  alone  marks  their  former  situation. 

These  ulcerations,  when  once  formed,  increase  with  great  rapid- 
ity, a  fact  of  which  I  have  more  than  once  seen  remarkable  illus- 
trations. A  patient,  aged  forty-nine  years,  was  admitted  under 
my  care  into  St.  Bartholomew's  Hospital,  whose  symptoms  con- 
sisted of  hemorrhage,  at  first  profuse,  afterwards  occurring  fre- 
quently and  withont  cause,  though  in  less  abundance,  and  with  it 
some  pain  in  the  back  had  of  late  been  associated.  The  uterus 
was  low  down,  quite  movable  in  the  pelvis,  and  not  much  enlarged. 
The  posterior  lip  was  thin,  and  seemed  healthy,  the  anterior  Avas 
thick,  hard,  and  nodulated,  thongh  tlie  mucous  membrane  covering 
the  surface  of  both  appeared  healthy  under  the  speculum.  Twelve 
days  afterwards  the  examination  was  repeated,  and  the  advance  of 
disease  within  this  short  time  was  very  remarkable.  The  posterior 
lip  was  now  no  longer  thin  and  natural,  but  thickened,  puckered, 
and  uneven,  and  the  inner  surface  of  the  anterior  lip  Avas  irregidar, 
as  if  from  ulceration,  while  the  introduction  of  the  speculum  showed 
the  surface  to  be  uneven,  ragged,  black,  and  bleeding. 

I  have  seen  other  similar  cases,  but  none  in  which  the  occur- 
rence of  ulceration  w^as  so  sudden,  or  its  subsequent  progress  so 
rapid  as  in  this  instance.  It  is  not  easy  to  account  for  the  occur- 
rence of  ulceration  in  all  instances.  Commonly  it  is  preceded  by 
softening  of  the  morbid  deposit,  but  this  is  by  no  means  constant, 
for  in  the  very  instance  which  I  have  related,  and  in  others  too, 
in  which  it  has  been  possible  to  fix  the  date  of  the  ulceration,  and 
to  trace  its  subsequent  progress,  the  cancerous  substance  round 
the  ulcer  has  been,  and  has  still  continued  firm.  Mere  rapidity 
of  growth,  too,  does  not  of  itself  produce  ulceration,  for  some  in- 
stances of  rapidly  growing  medullary  cancer  of  the  womb  excite 
our  suspicion,  and  yet  obscure  our  diagnosis  by  the  absence  of 
ulceration  even  up  to  a  late  period.     All  that  we  can  venture  to 


MEDULLARY    CANCER.  281 

assert  with  reference  to  the  subject  is,  that  in  all  forms  of  cancer 
of  the  Avomb  (with  the  exception,  perhaps,  of  that  of  its  body), 
ulceration  and  the  formation  of  an  open  sore  take  place  sooner 
or  later;  and  further,  that  this  ulceration  may  occur  in  one  of 
two  ways,^  either  proceeding  from  within  outwards,  in  which  case 
it  is  preceded  by  softening  of  the  cancerous  tissues,  or  from  with- 
out inwards  ;  the  vitalit}'  of  the  investing  membrane  of  tlie  uterine 
lips  being  destroyed  first,  just  in  the  same  wa^^  as  the  vitality  of 
the  skin  is  sometimes  destroyed  over  a  cancerous  tumor  of  the 
breast. 

A  few  days  often  suffice  to  give  to  the  ulceration  the  dimen- 
sions and  even  the  depth  which  it  may  be  found  to  retain  for 
months  subsequently.  The  patient,  indeed,  grows  worse,  the  dis- 
charges continue,  composed  of  pus  from  the  ulcerated  surface, 
fetid  from  the  admixture  with  it  of  dead  and  decaying  materials, 
tinged  with  blood  from  the  giving  way  of  some  of  the  vessels 
distributed  to  the  granulations,  while  every  now  and  then  abun- 
dant hemorrhages  break  forth,  profuse  enough,  perhaps,  to  excite 
a})prehensions  even  for  the  patient's  present  safety.  If  we  ex- 
amine, we  find  sprouting  granulations  or  positive  fungous  out- 
growth from  the  surface,  and,  then,  after  a  time,  the  fungus  dis- 
appears, the  surface  feels  less  uneven,  the  edges  less  unhealthy, 
and  we  can  almost  persuade  ourselves  that  here  and  there  a  process 
of  cicatrization  has  begun.  And  yet  healing  does  not  take  place. 
"  The  cancer  sore  does  not  heal,  because  its  base,  the  cancer 
substance,  is  not  cicatrix  tissue,  and  consequently  can  form  no 
scar,  and  the  apparent  scars  Avhich  now  and  then  form  are  never 
lasting.  It  does  not  heal,  because  the  outgrowth  is  constantly 
going  on ;  it  does  not  heal,  because  no  skinning  takes  place  upon 
its  surface;  and,  lastly,  it  does  not  heal,  because  the  new-formed 
tissue  speedily  dies  again. "^  IS^ew  formation  and  death  of  the 
newly-formed  tissues  go  on  in  constant  succession;  a  series  of 
abortive  attempts  at  cure,  such  as  prevent  the  rapid  extension  of 
the  ulcer,  such  as  cheer  the  patient  with  delusive  hopes  of  re- 
covery, such  as  sometimes  mislead  the  unwary,  even  among  mem- 
bers of  our  own  profession  ,  and  such  as,  I  blush  to  say  it,  furnish 
the  wretched  charlatan  with  a  fair  pretext  for  the  most  despicable 
of  all  falsehoods ;  for  those  with  which,  for  his  own  behoof,  the 
doctor  (lares  to  impose  on  the  credulity  of  his  patient. 

Slowly,  however,  though  the  disease  may  sometimes  seem  to 
advance,  it  yet  does  advance,  cancerous  deposits  extending  from 
the  cervix  into  the  substance  of  the  body  of  the  uterus;  the  new- 

'  Sf(>,  with  rofcroiioo  to  this  subject,  Paffot,  op.  cif.,  vol.  ii,  p.  884. 

2  Bnu'li,  Uebcr  die  Diet ff nose  der  bosartiyen  Gesc/nciitnte,  8vo.,  Mainz.  1847,  p.  454. 
Tho  few  isohited  instance.s  of  spontaneou.s  cure  of  cancer  limited  to  X\w  poriio  vagi- 
nnlis  do  not  invalidate  the  general  truth  of  this  statement.  Sucli  a  cure  takes  place, 
accordini^  to  K<ildtan.-ky,  I'ftfliol.  Aiuttomie,  3d  cd.  vol.  iii,  \>.  4i)."),  by  a  proees.s  of 
slounliinn'  ulceration  ;  the  consc(iuiMit  loss  of  substance  leavini;  a  funnel-shaped 
scar,  witli  its  i\\w\  directed  ui)\varils  towards  the  internal  orifice  of  the  uterus.  See 
a  case  of  Scanzoni's,  op.  cit.,  p.  '2S2;  and  some  remarks  of  Wagner,  Der  Qcbdr- 
inutlcrkrebs,  8vo.,  Leipzig,  1858,  i>.  27. 


282  CHANGES    IN    THE    UTERUS 

formed  tissues  dying,  and  dying;  on  the  whole  to  a  greater  extent 
than  they  are  reproduced,  until  at  length  the  lips  of  the  os  are 
quite  destroyed,  the  portio  vaginalis  of  the  cervix  is  destro^-ed  too, 
and  a  widely  gaping  opening,  with  thick,  hard,  and  irregular  edges, 
is  all  that  is  left  to  mark  the  point  where  the  womb  begins,  and 
the  canal  leading  to  it  ends.  Often,  though  not  invariably,  a  step 
preliminary  to  this  occurrence  is  the  formation  of  adhesions  be- 
tween the  lips  of  the  uterus  and  the  contiguous  surfaces  of  the 
vagina.  Sometimes  these  adhesions  are  limited  to  one  lip,  often 
they  involve  both,  and  to  them  is  in  a  great  riieasure  due  that  ap- 
parent shortening  of  the  vagina  which  is  very  marked  in  many 
cases  of  uterine  cancer,  and  which  does  not  at  all  imply  the  pre- 
vious occurrence  of  any  descent  of  the  womb.  In  the  softer 
kind  of  medullary  cancer,  in  which  this  condition  is  met  with 
most  frequently,  and  in  the  greatest  degree,  the  surface  of  the 
portio  vaginalis  and  the  walls  of  the  vagina  become  sometimes  so 
completely  fused  together  that  a  mere  thickened  ring  is  all  that 
indicates  the  situation  of  the  mouth  of  the  womb.  Even  this,  at 
length,  becomes  indistinct,  owing  to  the  extension  of  the  cancer- 
ous disease  along  the  vaginal  walls,  and  the  finger  at  last  diseov^ers 
no  distinction  between  the  uterus  and  vagina,  but  finds  only  that 
the  uneven  walls  of  the  canal  end  in  a  cavity  filled  with  a  dirty 
putrilage. 

Sometimes,  indeed,  this  fusion  between  the  two  surfaces  does 
not  take  place,  but  nevertheless  the  vagina  becomes  almost  always 
implicated  in  the  advance  of  the  disease.  Cancerous  deposit  takes 
place  in  its  cellular  tissue,  confined  at  first  pretty  much  to  the  roof 
of  the  vagina,  where  it  produces  that  thickening,  hardness,  and 
resistance,  which  render  the  cancerous  womb  less  movable. than 
natural.  With  the  lapse  of  time  the  deposit  both  becomes  more 
considerable  at  its  original  scat,  and  also  extends  further  and 
further  along  the  canal,  shortening  as  well  as  thickening  it,  while 
general  hypertrophy  of  the  tissues  tends  to  the  same  result.  Nor 
is  the  disease  confined  to  the  substance  of  the  vagina,  but  it  aftects 
the  mucous  lining  in  almost  every  instance,  and  this,  as  might  be 
expected,  most  remarkably  in  the  immediate  vicinity  of  the  womb. 
The  whole  mucous  membrane,  indeed,  is  often  red  and  inflamed, 
but  as  the  neck  of  the  uterus  is  approached  it  is  also  found  soft- 
ened and  thickened.  Small  spots  of  whitish  cancerous  deposit, 
from  the  size  of  a  pin's  head  to  that  of  a  barley-corn,  not  unfre- 
quently  beset  the  upper  part  of  the  canal,  and  unhealthy,  super- 
ficial ulcerations,  usually  irregular  in  form,  and  having  a  transverse 
direction,  are  often  present.  These  ulcerations  are  said  by  M. 
Lebert*  seldom  to  have  a  cancerous  base,  and  are  probably  due  in 
great  measure  to  the  acrid  nature  of  the  discharge  in  which  the 
upper  part  of  the  canal  is  almost  constantly  bathed.  What  ren- 
ders this  opinion  the  more  probable  is,  that  in  cases  of  epithelial 

1  Op.  cit,  p.  230. 


WITH    THE    ADVANCE    OF    CANCEK.  283 

cancer  in  which  this  discharge  is  often  absent,  the  ulcerations  are 
also  commonly  wanting. 

It  is  almost  needless  to  say  that  while  disease  advances  at  the 
lower  part  of  the  uterus,  the  rest  of  the  organ  is  not  left  in  a 
healthy  state.  If  life  is  sufRciontly  prolonged,  the  deposit  by 
degrees  extends  further  and  further  upwards,  till  even  as  high  as 
the  ligaments  of  the  ovaries,  or  sometimes  higher  still,  the  walls 
of  the  organ  are  thickened  by  infiltration  of  cancerous  matter,  or 
are  completely  converted  into  it.  This,  however,  is  not  the  only 
cause  of  that  enlargement  of  the  whole  uterus  which  is  met  with 
in  almost  ever}'^  case  of  carcinoma.  In  other  organs  of  the  body, 
the  advance  of  cancerous  deposit,  and  the  wasting  and  disappear- 
ance of  the  proper  tissue  of  the  part,  go  on  simultaneously  and  in 
equal  proportions.  In  the  case  of  the  uterus,  however,  that  dis- 
position to  growth  and  development  of  which  we  have  seen  so 
many  illustrations,  shows  itself  even  during  the  progress  of  ma- 
lignant disease.  The  walls  thicken  in  parts  which  the  cancer  has 
not  yet  reached,  for  the  increased  afflux  of  blood  brings  with  it 
an  increased  activity  of  growth,  and  even  in  those  situations 
where  the  malignant  deposit  is  abundant,  there  remains  up  to  a 
late  [)eriod  a  layer  of  muscular  fibre  bounding  it  externally;  the 
product,  as  I  imagine,  of  new  formation,  not  simj)ly  the  residue 
of  the  original  parietes  of  the  organ. 

But  though  the  cancerous  disease,  either  for  the  reason  which  I 
have  assigned,  or  on  some  other  account  as  yet  inexplicable, 
seldom  reaches  to  and  involves  the  external  surfiice  of  the  womb, 
its  mucous  lining  has  no  such  immunity  from  disease.  Its  con- 
dition, however,  is  very  variable.  Sometimes  nothing  more  is 
apparent  than  a  general  and  intense  redness  of  the  interior  of  the 
womb;  but  much  more  frequently  the  uterine  lining  membrane 
is  covered  by  a  dark  offensive  secretion,  and  is  beset  here  and  there 
by  small  white  deposits  of  cancer.  If  disease  is  more  advanced, 
the  mucous  membrane  is  absent,  at  any  rate  from  the  lower  part 
of  the  uterine  cavity,  and  the  surface  is  uneven  and  granular  from 
the  infiltration  of  cancerous  deposit  into  the  uterine  tissue.  On 
one  occasion,  too,  T  found  the  wdiole  interior  of  the  womb  lined 
by  a  white  membraniform  layer  of  cancerous  deposit,  beneath 
W'hich  its  substance  was  irregular  and  granular,  as  if  ulcerated. 

This  partial  destruction  of  its  mucous  lining,  and  this  granular 
state  of  its  interior,  occasion  that  roughness  which  the  finger  so 
constantly  perceives  when  introduced  within  the  orifice  of  the 
cancerous  womb.  There  is,  however,  besides,  in  many  instances 
of  uterine  carcinoma,  a  distinct  polypoid  cancerous  outgrowth, 
which  s[)rings  from  low  down  in  the  cavity  of  the  womb,  or  from 
the  upper  part  of  its  cervix,  seldom  attaining  any  considerable 
size,  but  varying  from  month  to  month,  and  usually  disappearing 
altogether  as  ulceration  advances,  and  as  the  uterine  structure  is 
with  its  advance  mor(>  and  more  extensively  destroyed.  Besides 
these,  which  are  usually  but  temporaiy  phenomena,  there  are  dis- 
tinct malignant  polypi,  concerning  which  I  must  say  more  pres- 


284  CHANGES    ON    EXTERIOR    OF    UTERUS 

ently,  but  about  which  it  may  suffice  now  to  mention  that  they 
may  be  formed  independently  of  disease  of  the  os  or  cervix  uteri, 
thongh  those  parts,  too,  become  almost  invariably  involved  in  the 
progress  of  the  cancerous  growth. 

If  now  from  the  substance  of  the  womb  and  its  interior  we  pass 
to  the  study  of  the  alterations  which  cancerous  disease  brings  about 
on  its  external  surface,  we  shall  find  occasion  to  notice  many  im- 
portant changes,  though  none  perhaps  so  striking  as  those  which 
we  have  already  observed.  Many  circumstances  concur  to  pro- 
duce that  firm  fixing  of  the  uterus  in  the  pelvic  cavity  which  is 
observable  in  almost  every  instance  of  carcinoma  of  the  medullary 
kind,  except  in  its  very  earliest  stages.  It  is  partly  brought  about 
by  a  chronic  form  of  peritonitis,  which  is  generally,  though  not 
constantly  limited  to  the  parts  in  the  immediate  vicinity  of  the 
pelvis,  and  which  glues  the  womb  to  the  rectum  and  bladder. 
This,  however,  is  not  its  only  cause,  but  infiltration  of  cancerous 
matter  between  the  uterus  and  adjacent  parts,  and  between  the 
folds  of  the  broad  ligament,  tends  to  fix  it  in  the  pelvis,  and  to 
form  it  and  the  parts  connected  with  it  into  one  immovable  mass. 
These  deposits  usually  take  place  on  the  visceral  surface  of  the 
peritoneum,  and  are  sometimes  so  extensive  as  to  be  the  apparent 
occasion  of  a  degree  of  wasting  of  the  womb  itself,  Avhich  I  have 
once  or  twice  found,  in  the  midst  of  abundant  medullary  deposit, 
small  and  shrunken,  and  its  outer  surface  rough,  as  if  partially 
eroded  or  destroyed  by  the  morbid  structure.  While  these  deposits 
are  but  inconsiderable,  they  may  still  be  seen  in  small  patches 
beneath  the  peritoneum ;  but  with  their  increase  the  peritoneum 
too  becomes  involved,  and  at  length  is  undistinguishable  in  the 
midst  of  the  large  mass  of  cancerous  disease  which  conceals  the 
uterus  and  its  appendages  from  view.  In  cases  where  these 
deposits  are  most  abundant,  it  is  by  no  means  unusual  to  find 
softened  cancerous  matter  in  the  pelvic  cavity,  or  between  the 
folds  of  the  broad  ligaments  ;  while  sometimes  the  intestines  are 
matted  together  above  the  pelvic  brim,  so  as  to  form  the  uj^per 
wall  of  an  irregular  cavity  lined  with  cancerous  matter,  while  now 
and  then  a  real  fecal  abscess  is  produced  by  tlie  extension  of  the 
disease  to  the  intestines,  and  their  consequent  perforation. 

More  frequent  than  the  actual  destruction  of  the  peritoneum  by 
deposits  of  cancer  beneath  it,  is  the  occurrence  of  numerous  small 
masses  of  the  same  substance  on  its  outer  surface.  These  are 
sometimes  flat  and  sessile,  like  small  tubercles  distributed  over 
it;  at  other  times  they  are  connected  with  the  serous  membrane 
by  a  small  and  slender  membranous  pedicle,  similar  to  that  by 
which  small  fibrous  outgrowths  are  not  infrequently  attached  to 
the  fundus  and  adjacent  parts  of  the  womb.  On  two  occasions  I 
have  also  found,  in  the  midst  of  the  cancerous  substance  Avhich 
enveloped  the  uterus,  serous  cysts  of  the  size  of  a  filbert,  contain- 
ing a  rather  deep  straw-colored,  transparent  serum,  their  walls 
thin,  their  outer  surface  free,  theirinner  connected  with  the  uterus 
itself  by  the  interposition  of  a  layer  of  cancerous  substance  of 


WITH    THE    ADVANCE    OF     CANCER.  285 

uncertain  thickness.  In  one  instance,  five  cysts  were  present,  and 
the  material  which  surrounded  them,  and  Vvhich  al.-o  had  matted 
together  the  uterine  appendages,  was  intermingled  fat  and  cancer 
substance.  In  the  other  case,  there  was  only  one  cyst,  but  it  also 
was  surrounded  by  a  very  abundant  deposit  of  cancer.  These 
cysts  showed  no  sign  of  endogenous  growth  in  their  interior,  but 
appeared  to  be  simple  serous  cysts,  such  as  sometimes  form  on 
the  exterior  of  the  uterus,  independent  of  any  other  disease.  I 
am  therefore  uncertain  in  what  relation  they  stood  to  the  cancer- 
ous deposits,  whether  in  that  of  mere  accidental  complication,  or 
whether  the  connection  between  the  two  was  more  intimate.' 

Reference  has  ah'eady  been  made  to  the  formation  of  adhesions 
between  the  uterine  lips  and  the  vaginal  walls,  and  it  is  obvious 
enough  that  when  this  takes  place,  the  extension  of  disease  to  the 
substance  of  the  vagina  is  almost  sure  to  follow.  It  is  matter  of 
observation,  however,  that  the  anterior  vaginal  wall  and  the 
bh^dder  are  much  more  frequently  involved  by  the  advance  of 
uterine  cancer  than  are  its  posterior  wall  and  the  rectum.  It  has 
been  attempted  to  explain  this  occurrence  by  the  assum])tion  that 
cancer  oftener  attacks  the  anterior  than  the  posterior  lip  of  the 
uterus ;  but  facts  do  not  bear  out  this  assertion,  and  my  own  ex- 
perience, indeed,  would  lead  me  rather  to  the  conclusion  that 
cancer  is  oftener  limited  to  the  posterior,  and  that  certainly  the 
disease  of  the  posterior  lip  is  often  further  advanced  than  that  of 
the  anterior.  The  intimate  connection  between  the  neck  of  the 
womb  and  the  bladder,  parts  which  are  separated  only  by  the 
intervention  of  a  fold  of  the  pelvic  fascia,  while  posteriorly  the 
peritoneum  descends  even  below  the  level  of  the  commencement 
of  the  portio  vaginalis,  accounts  much  more  satisfactorily  for  the 
more  speedy  infiltration  of  cancerous  matter  into  parts  contiguous 
with  the  front  than  with  the  back  of  the  organ.^ 

Though,  perhaps,  not  strictly  in  place,  it  ^vill  3'et  be  convenient 
to  add  a  few  words  more  about  the  afi'ection  of  the  bladder  in  cases 
of  uterine  cancer.  It  is  by  no  means  unusual,  independent  of  any 
trace  of  cancerous  deposit  in  the  organ,  to  find  the  mucous  mem- 
brane of  the  bladder  intensely  congested  and  of  a  deep  red  color, 
sometimes  inflamed,  even  ulcerated,  pus  covering  its  rugre,  and  all 
the  coats  of  the  organ  thickened,  showing,  what  indeed  the  dysuria 

1  In  all  the  cases  of  serous  cysts  of  the  uterus  described  by  Huguier  in  his  very 
Talual)ic  Es-say  in  vol.  i  of  the  Menioires  de  V Acadeinie  de  Cliirnrgie,  chap,  ii-,  pp. 
2!t")-32.j,  and  plates  iv  and  v,  the  cysts  were  sub-peritoneal.  Those  which  I  ob- 
served in  the  two  cases  above  described  were  similar  to  the  cy.st.s  delineated  by 
Bt)ivin  and  Dugfes  in  plates  xiv  and  xxxiii,  tig.  1,  of  their  ^1^/as,  but  of  which  they 
give  no  particular  descrijition. 

■^  AVagner,  o]).  cit.,  pp.  4'.)  and  60,  gives  the  proportions  as  38  per  cent,  of  the 
former  to  10  per  cent,  of  the  latter.  Jlis  data,  however,  bring  out  a  fact  for  which 
I  was  not  prepared — namely,  the  much  greater  frequency  of  recto-vaginal  than  of 
vesico-vaginal  fistula  as  the  result  of  cancerous  disease.  It  ajipears  that  while 
there  were  but  twenty-eight  cases  of  vesico-vaginal  listula  in  eighty-three  instances 
of  cancerous  disease?  of  the  bladder,  tlstulous  communication  with  the  vaginft 
existed  in  twenty-four  out  of  thirty-three  cases  in  which  cancer  had  implicated 
the  rectum. 


286  AFFECTION    OF    THE    BLADDER    IN     CANCER. 

during  the  patient's  life  but  too  constantly  announces,  how  close 
the  sympathy  is  between  the  bladder  and  the  womb.  The  mode 
in  which  the  first  anatomical  evidence  of  positive  disease  of  the 
bladder  appears  is  not  constant.  Sometimes  the  mischief  seems 
entirely  to  proceed  from  without  inwards,  and  then  at  one  spot, 
where  the  bladder  and  vagina  are  closely  united,  the  mucous 
membrane  of  the  former  viseus  may  present  a  slightly  flocculent 
appearance.  If  touched,  it  will  be  found  to  be  softened ;  if  pressed 
■  on  with  a  probe,  it  will  give  way  ;  the  cancerous  deposit  has  gradu- 
ally destroyed  all  the  intervening  tissues,  and  a  few  da^'s  more 
would  have  sufficed  for  the  production  of  a  fistulous  opening.  In 
other  instances,  disease  attacks  the  bladder,  secondarily  indeed, 
but  independently  of  mere  extension  to  it  by  continuity  of  tissue. 
Deposits  of  cancer,  in  the  form  of  small  flat  whitish  tubercles,  take 
place  beneath  its  mucous  membrane;  not  limited  to  that  part 
where  the  uterus  or  the  vagina  and  bladder  are  in  immediate  con- 
tact, though  generally  much  more  abundant  there  than  elsewhere. 
These  tubercles  enlarge  somewhat,  though  they  do  not  coalesce 
nor  attain  any  considerable  size,  but  they  destroy  the  mucous 
membrane  above  them,  while  that  of  the  rest  of  the  organ  is  gener- 
ally inflamed,  thickened,  and  sometimes  even  ulcerated.  When 
the  fistulous  opening  has  once  formed,  the  bladder  undergoes  all 
those  changes  that  attend  a  vesico-vaginal  fistula,  however  pro- 
duced, only  aggravated  by  the  constant  advances  of  the  disease  by 
which  the  fistula  was  occasioned. 

But  to  return  to  that  more  special  study  of  cancer  of  the  womb 
itself  which  is  our  present  business,  I  may  observe,  that  though  the 
descri}ition  of  the  disease  already  given  holds  good  to  a  great  extent 
of  all  tbrms  of  uterine  cancer,  there  are  some  varieties  of  the  disease 
in  which  deviations  occur  from  its  most  common  course.  It  has 
been  stated  as  a  general  rule,  that  cancer  begins  in  the  neck  of 
th«  womb,  and  this  statement  is  open  to  almost  as  few  exceptions 
as  the  directly  opposite  one  with  reference  to  the  exclusive  seat  of 
fibrous  tumors  in  the  body  of  the  organ.  In  three,  liowever,  out 
of  one  hundred  and  seventy  cases  of  uterine  cancer,  the  disease 
occupied  the  body  of  the  organ,  and  ran  its  course  to  a  fatal  issue 
without  the  occurrence  of  ulceration  of  the  os  uteri,  or  of  any 
change  in  its  condition,  such  as  during  life  could  lead  to  the  suspi- 
cion of  its  being  the  seat  of  malignant  disease,  though  its  tissue 
was  found  after  death  infiltrated  with  cancerous  deposit.  In  all 
of  these  cases  the  enlargement  of  the  uterus  was  very  considerable ; 
in  one  it  measured  five  inches  in  length,  in  a  second  six  inches, 
and  in  the  third  was  nearly  as  large  as  the  adult  head.  Tliis  in- 
crease of  size  was  due  in  two  of  the  cases  to  the  extreme  thickening 
of  the  uterine  walls  by  infiltration  of  cancerous  deposit,  which  in 
one  had  converted  the  whole  organ  into  a  tolerably  uniform  mass 
of  soft,  indistinctly  fibrous  tissue,  of  a  dirty  grayish-white  color, 
soaked  in  a  dirty  serum,  very  soft,  but  tearing  most  readily  in  a 
longitudinal  direction,  while  no  trace  of  mucous  membrane  was 
discoverable,  nor  any  remains  of  uterine  cavity  beyond  half  an 


CANCER  OF  THE  BODY  OF  THE  UTERUS.       287 

inch  from  the  orifice  of  the  womb,  which  was  small  and  circular, 
and  outwardly  presented  no  evidence  of  disease.  In  the  other  case, 
the  walls  of  the  uterus  were  similarly  thickened,  though  in  a  less 
degree,  and  the  uterine  cavity  was  not  obliterated,  but  a  mass  of 
soft  medullary  cancer,  of  the  size  of  a  walnut,  projected  into  it, 
springing  from  a  little  above  the  situation  of  the  internal  os  uteri. 
Externally,  the  lips  of  the  os  uteri  were  healthy,  their  surface  per- 
fectly smooth  and  of  a  vivid  red  color.  This  character  continued 
to  just  within  the  cervix,  but  there  the  mucous  membrane  at  once 
became  roughened,  of  a  red  color,  with  dead-white  spots  of  can- 
cerous deposit  showing  through  it  everywhere/  A  similarly 
hcahhy  state  of  the  os  existed  in  the  third  instance,  in  which  the 
uterus  measured  five  inches  in  length.  The  organ  in  that  case 
was  surrounded  by  a  mass  of  softening  carcinomatous  matter,  but 
its  walls  were  not  infiltrated  with  malignant  deposit.  The  in- 
creased size  of  the  womb,  indeed,  was  due  to  expansion  of  its 
cavity;  not  at  all  to  thickening  of  its  walls;  but  their  inner  sur- 
face presented  a  very  remarkable  appearance,  being  everywhere 
beset  hy  small  warty  growths,  or  irregularities,  among  which  were 
one  or  two  rather  larger  than  the  rest,  but  even  these  did  not  ex- 
ceed the  size  of  a  pea.  These  granulations  were  quite  sessile,  and 
the  surface  altogether  looked  more  like  that  of  a  clu'onically  ulcer- 
ated bladder  than  of  a  part  the  seat  of  morbid  deposit.  In  the 
substance  of  these  granulations  no  distinct  cancer-cells  were  found, 
but  at  the  fundus  of  the  uterus,  where  the  walls  were  generally 
very  thin,  there  was  an  aperture  of  communication  large  enough 
to  allow  the  finger  to  pass  between  the  cavity  of  the  womb  and  the 
mass  of  carcinoma  which  surrounded  it.  Here,  too,  the  uterine 
wall  was  softened  and  disintegrated,  and  seemed  infiltrated  with 
the  same  kind  of  matter. 

Besides  these  cases,  two  others  out  of  the  total  one  hundred  and 
seventy  presented  a  great  preponderance  of  disease  in  the  interior 
of  the  womb,  though  the  lips  were  not  in  a  healthy  conditii)n.  It 
was  clear,  however,  in  both  instances,  that  the  mischief  had  })ro- 
ceeded  from  within  outwards,  not  in  its  usual  course;  and  I  am 
dispos<:H;l  to  think  that  the  conmiencement  of  cancerous  disease  in 
the  interior  of  the  womb,  instead  of  about  its  orifice  or  in  the  sub- 
stance of  its  neck,  is  not  of  that  extreme  rarity  which  is  generally 
supposed. 

Lastly,  in  connection  with  those  cases  in  which  the  os  uteri 
esca[)es  the  cancerous  deposit,  or  l^ecomes  afiectcd  only  second- 
arily, some  mention  must  be  made  of  those  rare  instances  in  which 
poljipi  of  malignant  structure  grow  from  the  interior  of  the  uterus, 
independent  of  previous  disease  of  its  orifice,  lleference  has 
already  been  made  to  the  frequent  formation  of  polypoid  out- 

1  A  brief  but  intcrosting  (Icscriiitioii  of  t<ovoral  cases  of  tbis  kiinl  is  given  by  Dr. 
Sini]isim  ill  liis  Ohsfrfric  ^Tr»|l)lni,  &c.,  vol.  i,  p.  1'.*:^,  ami  a  iiiorti  or  less  detailed 
iiccoiiiit  of  iiianv  otbers  collected  from  dilferent  sources  will  be  found  in  Wagner, 
oj).  fit.,  pp.  12li-133. 


288       CANCER  OF  THE  BODY  OF  THE  UTERUS. 

growths  of  malignant  structure  during  the  course  of  general 
uterine  cancer,  but  these  outgrowths  are,  for  the  most  part,  of  in- 
considerable size,  constitute  but  a  small  part  of  the  general  mass 
of  disease,  and  disappear  with  the  advance  of  the  carcinoma. 
!Now  and  then,  however,  at  a  time  when  the  lips  of  the  os  are 
still  unaffected,  an  outgrowth  of  cancerous  tissue,  generally  of  the 
medullary  kind,  springs  from  the  interior  of  the  womb,  and  de- 
scends into  the  vagina.  The  point  of  origin  of  such  malignant 
polypi  is  usually  low  down  in  the  cavit}^  of  the  womb,  or  actually 
within  the  canal  of  the  cervix,  but  occasionally  they  spring  from 
its  fundus.  Of  this  a  remarkable  illustration  is  given  by  Boivin 
and  Duges,  and  an  instance  of  it  came  under  my  own  observation 
some  years  since  at  the  Middlesex  Hospital,  into  which  institu- 
tion a  woman  came  to  die,  apparently  of  ascites.  An  abundant 
and  very  offensive  vaginal  discharge  attracted  attention  to  the 
state  of  her  womb,  when  a  polypus  considerably  larger  than  the 
fist  was  discovered  in  the  vagina.  After  her  death,  in  addition  to 
extensive  cancerous  deposits  in  various  abdominal  viscera,  the 
walls  of  the  uterus  were  found  thickened  by  medullary  deposit, 
and  its  cavity  distended  by  the  polypus,  which  sprang  by  a  pedi- 
cle half  the  size  of  the  wrist  from  the  fundus  of  the  womb.  The 
polypus  Avas  of  a  very  soft  texture,  and  possessed  of  considerable 
vascularity.  One  other  case  of  cancerous  polypus  has  come  under 
my  observation.  The  outgrowth  was  of  much  smaller  size,  and, 
as  well  as  could  be  ascertained,  sprang  from  low  down  in  the  body 
of  the  womb.  It  projected  but  a  short  distance  into  the  vagina, 
and  the  lips  of  the  os  uteri  looked  healthy,  though  there  was  some 
degree  of  thickening  and  induration  of  the  posterior  lip.  I  be- 
lieve, indeed,  that  though  the  formation  of  the  malignant  poly- 
pus may  precede  other  disease  in  the  womb,  yet  the  cancer  before 
long  extends  to  the  uterine  walls,  and  I  am  not  aware  of  malig- 
nant outgrowths  having  ever  been  found  in  an  otherwise  healthy 
uterus. 

I  believe  that  I  have  twice  met  with  alveolar  cancer  of  the 
womb,  but  in  one  instance  only  have  I  had  the  opportunity  of 
corroborating  my  opinion  by  an  examination  after  death.  In  that 
case  the  lips  of  the  os  uteri  were  nearly  destroyed,  and  a  layer  of 
dense  medullary  carcinoma  formed  the  base  from  which  projected 
numerous  semi-transparent  warty  granulations,  occupying  the 
whole  interior  of  the  uterus,  and  filled  with  a  rather  firm  semi- 
transparent  gelatinous  matter,  such  as  Lebert,^  who  appears  to 
have  met  with  this  condition  several  times,  speaks  of  as  its  char- 
acteristic. 

The  epithelial  cancer  of  the  uterus  presents  itself  under  two 
forms ;  either  assuming  the  character  of  a  granular  outgrowth 
from  the  lips  of  the  ute-rus,  or  else  of  an  intractable  ulceration  of 
their  surface.  In  its  most  characteristic  form,  the  first  variety  is 
the  caulifioiver  excrescence  of  Dr.  John  and  Sir  Charles  Clarke; 

*  Traite  des  Maladies  Cancereuses,  8vo.,  Paris,  1851,  p.  217. 


EPITHELIAL     CANCER.  289 

» 

but  of  far  more  common  occnrrence  are  cases  wliicli,  tliongh 
essentially  the  same,  present  points  of  difference  approximating 
them  to  ordinary  medullary  cancer. 

In  its  very  early  stages,  epithelial  cancer'  of  the  womb  has  only 
twice  conic  under  my  observation  ;  for  the  comparatively  trifling 
symptoms  to  which  it  at  first  gives  rise  seldom  force  themselves 
upon  the  attention  of  our  patients.  In  one  of  the  instances-  in 
which  I  had  the  opportunity  of  seeing  the  disease  of  the  uterus  at. 
its  commencement,  it  was  secondary  to  the  same  atlection  in  the 
vagina,  but  in  the  other  the  vagina  was  perfectly  healthy.  In  the 
iirst  case  there  was  a  patch  of  tlie  size  of  a  shilling  on  the  surface 
of  the  [josterior  uterine  lip,  somewhat  raised  above  the  surround- 
ing surface,  of  a  vivid  red  color,  bleeding  readily,  and  with  a 
papillary  structure  so  fine  that  it  closely  resembU'd  the  pile  of  red 
velvet.  In  the  second  case  the  disease  occupied  the  anterior  part 
of  the  anterior  uterine  lip,  the  outer  edge  of  which  felt  sliarp-cut 
and  everted,  and  the  speculum  discovered  on  it  a  small  patch  of 
abrasion,  soft  and  velvety  to  the  touch,  and  seen  under  the  specu- 
lum to  be  beset  with  tine  sessile  granulations.  In  all  other 
instances  that  have  come  under  n)y  notice,  the  disease  has  been 
much  more  advanced,  the  cervix  of  the  womb  has  been  already 
somewhat  increased  in  size,  tlie  os  uteri  not  open,  but  its  lips  flat- 
tened and  expanded,  so  that  their  edge,  which  felt  a  little  ragged, 
projected  a  line  or  two  beyond  the  circumference  of  the  cervix, 
while  their  surface  was  rough  and  griuudarto  the  touch.  On  in- 
troducing the  speculum,  this  irregularity  was  seen  to  be  produced 
by  the  aggregation  of  numerous  small,  somewhat  flattened  papillse 
or  granulations,  of  a  reddish  color,  semi-transparent  appearance, 
and  often  bleeding  very  readily.  Sometimes  these  granulations 
continue  for  many  months,  scarcely  at  all  increasing  in  size  or 
altering  in  character;  and  then  on  one  or  other  lip  an  ulcerforms, 
witli  irregular,  excavated  edges,  and  the  case,  if  then  seen  for  the 
first  time,  would  scarcely  be  susi)ected  to  have  been  other  than  one 
of  ordinary  uterine  cancer.  Often,  however,  the  small  sessile 
papillae  increase  in  size,  and  form  a  distinct  outgrowth  from  the 
whole  circumference  of  the  os  uteri,  of  the  size  of  an  eg^g,  an  apple, 
or  even  of  a  greater  magnitude.  These  growths  are  split  u}>  by 
deep  fissures  into  loludes  of  various  sizes,  all  of  which,  however, 
seem  to  be  connected  together  at  their  base,  though  the  fissures 
are  so  deep,  and  their  directions  so  various,  that  it  is  seldom  pos- 
sible, when  the  growth  is  of  any  size,  to  distinguish  between  them 
and  the  os  uteri  itself  The  dimensions  of  these  growths  are  not 
in  general  the  same  througliout,  but  they  spring  from  the  surface 

1  I  have  rotainod  the  term  cancer  as  appliod  to  these  varieties  of  malifcmmt  dis- 
ease of  the  uterus,  beeaiis(!  I  do  not  feel  myself  competent  to  form  an  ind«'|ifndent 
opinion  with  reference  to  what  is  still  a  moot  point  between  the  hii;hest  authorities; 
and  bicause  the  general  tendency  of  epithelial  and  cancroid  diseases  of  the  womb 
is  to  become  associated  durin<;  their  projL|:ress  with  medullary  cancer  ;  r)ften.  indeed, 
they  lose  their  own  distinctive  features  completely,  mergiiiij;  them  in  those  of 
ordinary'  uterine  carcinoma. 

19 


290  CHARACTERS    OF    EPITHELIAL     CANCER. 

of  tlie  OS  uteri  by  a  short  tliick  pedicle  or  stem,  the  elongated  and 
hypcrtrophied  cervix,  and  then  expand  below  into  that  peculiar 
cauliflower-like  shape  from  which  their  name  has  been  derived. 
Even  the  most  careful  examination  generally  breaks  down  some 
of  the  tissue  of  the  growth,  and  produces  hemorrhage ;  but  if,  in 
spite  of  this,  the  finger  be  carried  down  to  its  base,  the  substance 
will  be  found  to  become  much  firmer,  and  at  the  same  time  to  be 
possessed  of  a  degree  of  sensibility  which,  though  but  low,  is 
much  greater  than  that  of  the  more  depending  part  of  the  tumor. 
Sometimes  the  outgrowth  is  confined,  at  any  rate  at  its  commence- 
ment, to  one  lip,  and  may  attain  a  considerable  size  before  the 
other  is  involved  in  the  disease.'  This  is  more  likel}^  to  occur  if 
the  posterior  tlian  if  the  anterior  lip  is  aft'ected,  and  for  the  ob- 
vious mechanical  reason  which  accounts  for  every  large  polypoid 
outgrowth  being  flattened  on  its  anterior  surface,  spheroidal  on 
its  posterior.  The  hollow  of  the  sacrum  allows  more  room  for  the 
development  of  any  outgrowth  than  is  afforded  by  the  compara- 
tively^ flattened  anterior  half  of  the  pelvic  cavity  bounded  by  the 
rami  of  the  pubes. 

Though  the  vagina  does  not  by  any  means  escape  from  a  par- 
ticipation in  the  disease,  and  a  granular  or  papillary  structure 
may  be  felt  sometimes  extending  over  its  roof,  and  for  some 
distance  along  one  or  other  wall,  yet  this  is  by  no  means  con- 
stant; and  so  long  as  the  disease  retains  its  original  characters 
well  marked,  the  disposition  to  involve  adjacent  parts  is  far  less 
than  in  ordinary  uterine  cancer.  The  tendency,  however,  to  pass 
into  ordinary  medullary  cancer,  or  to  become  associated  with  it, 
is  very  strong;  while  we  find  that  the  tumor  itself  undergoes  the 
same  processes  of  alternate  partial  death  and  partial  reproduction, 
as  we  have  noticed  in  other  forms  of  malignant  disease.  Usually 
tlie  outgrowth  in  the  course  of  time  disappears  in  part,  and  the 
irregular,  sharp-cut  edge  of  the  os,  whence  it  grew,  is  at  first  felt 
granular  and  uneven  within,  but  afterwards  grows  thicker  and 
nodulated,  assuming  by  degrees  all  the  characters  of  a  part  which 
has  from  the  first  been  the  seat  of  medullary  cancer,  while  the 
walls  of  the  organ  and  its  interior  likewise  undergo  just  the  same 
changes. 

Between  this  disease  and  genuine  cauliflower  excrescence  the 
differences  appear  to  be  of  degree  rather  than  of  kind.  In  the 
latter,  indeed,  the  eidthelial  cells  which  compose  it  are  of  the 
cylindrical  form,  but  its  more  obvious  peculiarities  consist  in  the 
larger  size  of  its  vessels,  in  the  greater  delicacy  of  their  walls, 
and  in  their  being  covered  by  a  thin  investment,  not  bound  to- 
gether into  a  comparatively  solid  mass  by  connecting  tissue,  but 
"hanging  in  fringes  almost  like  a  mass  of  uterine  hydatids;"^ 

1  Of  which  there  is  a  very  characteristic  drawing  in  Boivin  and  Dug^s'  Atlas, 
plate  xxiv,  fig.  1. 

2  This  not  inapt  comparison  is  made  by  Virchow  in  his  description  of  the  micro- 
scopic structure  of  these  grf)wths,  in  the  VerhandL  der  Phys.  Med.  Ge^ellschafi  in 

Wurzburg,  vol.  i,  p.  110,  whic!-  harmonizes  with  and  completes  previous  observa- 


I 


INTRACTABLE     ULCERATIONS     OF    THE     UTERUS.  291 

while  the  base  of  cancer  substance,  which  in  the  more  solid  growths 
is  deposited  very  early,  in  the  delicate  and  vascular  cauliflower 
excrescence  is  not  formed  till  a  much  later  period,  or  even  not  at 
all.  Their  intimate  structure,  however,  and  their  microscopic 
elements  are  just  the  same,  and  both  consist  of  hypertrophied 
papillae,  composed  of  epithelial  cells  richly  supplied  in  their  in- 
terior with  large  and  delicate  vessels,  and  covered  with  a  thickened 
layer  of  epithelium.  The  enormous  looped  capillaries  of  the  cauli- 
flower excrescence  explain  the  abundant  hemorrhages  and  the 
profuse  serous  discharges  that  attend  it,  while  the  absence  of  that 
solid  structure  which  is  found  in  other  forms  of  epithelial  cancer 
accounts  for  the  peculiarly  favorable  results  tluit  have  followed 
its  extirpation,  and  also  for  tlie  fact  that  after  its  removal  a  few 
shreds  are  all  that  remain  of  what  had  seemed  to  be  a  large  and 
firm  tumor. 

Ditference  of  opinion  exists  as  to  the  exact  nature  of  those 
intractable  ulcerations  of  the  os  and  cervix  uteri,  which,  in  accord- 
ance, as  I  believe,  with  the  preponderance  of  authority  on  the 
subject,  I  have  referred  to  epithelial  carcinoma,  but  which  are 
alleged  by  some  very  competent  observers  to  be  tuberculous. 
"When  speaking  of  uterine  tubercle,  I  made  mention  of  numerous 
small  deposits  of  a  yellowish  color  sometimes  met  with  on  the 
surface  of  the  os  uteri,  and  which,  if  punctured,  or  if  their  con- 
tents escape  spontaneously,  sometimes  leave  behind  small  slightly 
excavated  ulcers.  Their  tuberculous  character  did  not,  however, 
appear  to  me  to  be  clearly  substantiated,  since  I  had  never  ob- 
served any  general  fusion  of  the  deposits,  and  consequent  breaking 
down  of  the  tissue  of  the  cervix.  M.  Lisfranc,  however,"  has  de- 
scribed a  condition  which  has  never  come  under  my  own  notice, 
but  which  has  been  seen  and  described  by  M.  Robert,-  M.  Pichard,^ 
and  others,  who  relate  cases  illustrative  of  its  character,  and  wlio 
refer  it  to  the  breaking  down  of  tubercular  deposits  in  the  sub- 
stance of  the  cervix. 

"  These  tubercular  ulcerations  of  the  cervix  uteri,"  says  M. 
Robert,*  "  may  be  recognized  by  their  excavated  base,  their  grayish 
appearance,  and  the  presence  of  a  caseous  matter  in  the  midst  of 
the  muco-purulent  discharges  which  come  from  the  interior  of  the 
cervix.  They  may  also  be  known  by  the  presence  in  the  cervix 
of  tumors  of  uncertain  size,  of  a  rounded  form,  at  first  firm  and 
with  no  change  of -color,  afterwards  soft,  whitish,  yielding  to  the 
pressure  of  the  fingers,  and  giving  an  indistinct  sense  of  fluctua- 
tions. Very  <i;nocl  ro])resfntations  of  tho  gononil  aspect  of  those  jTrowths  an'  u.-iven 
by  Sir  C.  Chirko  in  vol.  ii,  pi.  i,  of  liis  \vori<  on  Diseasps  of  \Foinfn ;  by  Or.  ."^inip- 
son,  at  pp.  105  and  IGf!  of  his  Obstetric.  Works;  and  by  Dr.  Mayer,  in  vol.  iv  of 
the  Verhdndl.  der  Ucs.  f.  Gehurts/i.  in  /irr/lii,  which  also  contains  a  drawing  of  the 
a[)pearanees  jiresented  under  a  low  magnifying  |)ower. 

'   Clinif/ue  C/iirurfficale,  «&c.,  vol.  iii,  pp.  548-553. 

■^  Des  Affections,  ,yc.,  dii  Col  de  I'  Uterus,  Svo.,  Paris,  1848. 

"  Des  Ahus  de,  la  Caiiierisaiion,  tj-c,  duns  lea  Maladies  de  la  Matrice,  8vo.,  Paris, 
1846,  pp.  124-132. 

*  Op.  cil.,  p.  48. 


292         CORRODING  ULCER  OF  THE  UTERUS. 

tion.     These  tumors  are  formed  by  the  tubercular  matter  still  in 
a  crude  state,  or  in  course  of  softening. 

"  It  is,  moreover,  to  be  observed  that  these  scrofulous  ulcerations 
are  almost  always  accompanied  by  considerable  engorgment  of 
the  cervix  uteri,  a  condition  which  is  due  either  to  the  presence  of 
masses  of  tubercle  still  unsoftened,  or  to  some  tubercular  infiltra- 
tion still  remaining,  or  lastly,  to  that  inflammatory  process  which 
accompanies  the  softening  and  elimination  of  this  kind  of  morbid 
product.  This  last  circumstance  may  obscure  the  diagnosis  of  the 
case,  and  lead  to  the  belief  that  the  engorgements  or  the  ulcerations 
are  of  a  malignant  character,  an  error  which  Lisfranc  confesses 
that  he  fell  into  several  times." 

These  appearances,  however,  receive  a  different  interpretation 
when  the  microscope  is  called  in  to  aid  our  researches.  The 
softened  matter  is  found  not  to  consist  of  the  elements  of  tubercle, 
but  of  epithelial  cells  similar  to  those  of  the  uterine  mucous 
membrane,  while  the  indurated  callous  structure  which  forms  the 
base  of  the  ulcer  is  formed  of  a  mixture  of  fibro-plastic  and  epi- 
dermoid materials.  In  short,  as  M.  Robin'  says,  this  kind  of 
ulcer  is  to  the  uterus  what  lupus  or  cancroid  ulcers  are  to  the 
face,  the  chief  difl^erences  between  them  depending  on  the  constant 
exposure  of  the  latter  to  the  air,  and  the  constant  contact  of  the 
former  with  the  mucous  and  other  secretions  of  the  vagina. 

One  affection  still  remains  to  notice,  which,  though  less  strictly 
deserving  to  be  ranked  with  cancer  than  were  those  varieties  of 
malignant  disease  which  we  have  just  now  been  studying,  yet  will 
find  here  perhaps  its  fittest  place.  The  late  Dr.  John  Chirke  was 
the  first  writer  who  described,  under  tlie  name  of  corroding  ulcer, 
a  peculiar  form  of  destructive  ulceration  of  the  os  and  cervix  uteri, 
beginning  at  the  mucous  membrane  which  covers  it,  involving  the 
whole  circumference  of  the  os,  and  utterly  destroying  both  it  and 
the  subjacent  parts,  but  diftering  from  carcinoma  in  the  absence 
of  any  thickening,  hardness,  or  deposit  of  new  matter  in  its  vicinity. 
Not  to  dwell  on  certain  differences  between  its  symptoms,  and 
those  of  ulcerated  carcinoma,  the  fiict  that  the  corroding  ulcer 
may  continue  for  several  years  without  causing  any  very  formidable 
symptoms,  while  death  takes  place  speedily  as  well  as  inevitably 
in  ulcerated  cancer,  points  to  some  essential  difierence  between  the 
two  diseases. 

Its  real  nature  has  given  rise  to  much  difference  of  opinion,  and 
the  rarity  of  the  affection  has  been  a  great  obstacle  to  the  thorough 
understanding  of  its  nature.  There  can  be  no  doubt,  however,  but 
that  it  ought  to  be  classed  with  rodent  ulcers,  as  indeed  it  has  been 
by  all  recent  microscopic  observers,  for,  like  them,  its  aspect,  rate, 

1  The  conjoint  testimony  of  Robin,  Archhes  de  Medecine,  August,  1848,  pp.  407- 
411  ;  of  Lebert,  Maladies  Caiicereuses,  p.  218  ;  and  of  Hiinover,  J)as  EjntheUoma , 
8vo.,  Leipzig,  1852,  p.  126,  may  be  taken  as  decisive  on  this  point.  It  is,  I  think, 
extremely  doubtful  whether  Dr.  Gibbs's  case  of  alleged  extensive  tuberculous  ulcer- 
ation of  the  uterus  and  bladder,  described  at  p.  269  of  vol.  vi  of  Transactions  of 
the  Pathological  ISociety,  ought  not  rather  to  be  referred  to  this  category. 


SECONDARY     DEPOSITS     OF     CANCER.  293 

and  mode  of  progress  are  unlike  those  of  cancer,  while  neither 
cancer-cells  nor  epithelium  formations  are  present  in  the  adjacent 
tissues.^ 

One  point  only  connected  with  the  morbid  anatomy  of  uterine 
cancer  still  remains  for  notice,  and  that  concerns  the  frequency 
tvith  wliich  other  organs  become  affected  in  the  course  of  the  disease. 
I  apprehend  the  number  of  cases  to  he.  very  few  indeed  in  which 
cancer  has  not  extended  before  the  death  of  the  patient  by  con- 
tinuity of  tissue  from  the  uterus  itself  to  some  of  the  parts  imme- 
diately adjacent.  Thus,  for  instance,  it  is  certainly  very  unusual 
for  a  patient  to  die  of  uterine  cancer,  in  whom  there  does  not  exist 
some  degree  of  cancerous  infiltration  into  the  u[)per  part  of  the 
vagina  ;  and,  as  we  shall  see  hereafter,  the  frequency  of  this  occur- 
rence, even  at  a  comparatively  early  period  of  medullary  cancer, 
is  one  of  the  circumstances  which  most  of  all  interferes  with  the 
success  of  operative  proceedings  for  its  cure,  and  which  oftenest 
contraindicates  any  attempt  at  their  performance.  There  does, 
however,  seem  to  be  reason  for  believing  that  carcinoma  of  the 
uterus  is  oftener  at  its  conmiencement  confined  to  one  part,  and 
that  it  continues  so  for  a  longer  period  than  does  cancer  when 
situated  in  any  other  organ  .of  the  body,  though  in  neither  of  these 
respects  does  it  present  the  striking  differences  from  cancers  of  other 
parts  which  was  formerly  supposed,  and  in  which  one  would 
gladly  still  believe.  M.  Lebert^  states  that  the  evidence  of  general 
infection  of  the  system,  as  manifested  by  secondary  deposits  in 
other  organs,  existed  in  only  a  third  out  of  forty  five  cases  of 
uterine  cancer,  but  in  twenty-four  out  of  thirty-four,  or  in  five- 
sevenths  of  the  number  of  cases  of  cancer  of  the  breast.  These 
results,  however,  are  more  favorable  than  those  which  the  late 
Professor  Iviwisch  deduced  from  seventy-three  post-mortem  ex- 
aminations of  uterine  cancer  made  in  the  hospital  at  Prague. 
He  found  cancer  of  the  bladder  in  42  per  cent,  of  his  cases; 
Lebert^  only  in  13  per  cent. ;  pf  the  ovaries  in  19 ;  and  of  the 
lungs  in  7.5  per  cent. ;  while  Lebert  met  with  each  of  them  only 
in  the  proportion  of  4.4  per  cent.  These  discrepancies,  which  I 
am  not  able  from  personal  observation  to  explain,  are  yet  probably 
due  to  the  different  forms  of  cancer  having  occurred  in  different 
pro[)ortions  at  Paris  and  at  Prague ;  possibly  to  the  greater  fre- 
quency of  epithelial  cancer  in  the  former  city,  and  of  medullary 
cancer  in  the  latter.  In  any  future  statistical  table  showing  the 
frequency  of  cancerous  infection  of  the  system,  it  will  ob\  iously 
be  necessary  to  refer  the  cases  to  different  categories  according  to 
the  character  of  the  primitive  disease.  In  the  meantime  the 
knowledge  of  the  fact  that  such  infection  of  the  system  occurs 
perhaps  less  invariably,  probably  less  early  in  cancer  of  the  womb 
than  in  other  forms  of  tlie  disease,  may  serve  to  throw  a  feeble 

1  Hanover,  op.  cit,  p.  128.  2  Op.  clL,  pp.  239,  310,  394. 

3  Op.  cit.,  vol.  i,  p.  511. 


294  FREQUENCY    OF    CANCER. 

ray  of  hopefulness  over  the  gloomy  prospect  which  we  have  now 
to  contemplate  from  other  points  of  view.^ 


LECTURE    XX. 

MALIGNANT  OR  CANCEEOIJS  DISEASES  OF  THE  UTERUS. 

Their  fi'pqnency  ;  canses  influencing  the  occurrence  of  cancer, — as  age,  state  of  the 
menstrual  function,  its  mode  of  establishment,  childbearing ;  influence  of 
childbearing  accounted  for;  hereditary  tendency. 

Symptoms  of  cancer;  mode  of  onset,  and  first  symptom.  Pain,  its  character,  and 
causes.  Hemorrhage,  its  import ;  frequent  as  a  first  sym))tom,  and  why.  Dis- 
charges; cause  of  their  offensive  character,  and  of  variations  in  this  respect. 

Cancerous  cachexia;  its  characters. 

Two  exceptional  forms  of  cancer,  the  latent  and  the  acute. 

Influence  of  cancer  upon  labor. 

Diagnosis  of  uterine  cancer. 

Duration  of  the  disease. 

One  of  the  reasons  which  at  the  commencement  of  the  last  Lec- 
ture I  assigned  for  occupying  much  of  your  time  with  the  study  of 
carcinoma  of  the  uterus,  was  the  frequency  of  its  occurrence.  Our 
tables  of  mortality,  indeed,  do  not  at  present  enable  us  to  learn 
with  complete  accuracy  how  often  it  is  met  with,  but  they  furnish 
data  from  which  it  is  not  difficult  to  make  a  tolerable  ai)proxima- 
tion  to  the  truth.  It  appears  from  the  Seventeenth  lleport  of  the 
Registrar- General,^  that  the  mortality  from  cancer  throughout 
England  in  the  year  1851  amounted  to  1754  males,  4072  females. 
The  whole  of  tliis  excess  of  female  mortality  from  cancer  maybe 
confidently  attributed  either  to  cancer  of  the  breast  or  of  the 
womb.  According  to  Tanchou's  tables,^  however,  deduced  from 
the  mortuary  registers  of  Paris,  cancer  of  the  womb  was  more 
frequent  than  cancer  of  the  female  breast,  in  the  proportion  of 
2996  to  1147,  or  as  2.6  to  1.  Neither  this  statement,  however,  nor 
the  assertion  which  he  also  makes,  that  uterine  cancer  was  the 
cause  of  1.6  per  cent,  of  all  female  deaths  during  the  decennial 
period  to  which  his  calculations  refer,  can  be  received  as  abso- 
lutely correct,  though  it  is  my  impres.sion  that  neither  the  one  nor 
the  other  deviates  much  from  the  truth.  The  absolute  frequency 
of  uterine  cancer,  though  not  the  exact  proportion  which  it  bears 
to  other  fatal  diseases  of  the  female  sex,  receives  another  illustra- 

1  From  a  comparison  of  uterine  cancer  with  cancer  of  the  stomach,  Wagner, 
op.  ciL,Tp.  100,  comes  to  the  conclusion,  and  I  very  much  fear  the  correct  conclu- 
sion, that  in  respect  of  the  extension  of  the  disease  from  its  original  seat,  and  of 
the  occurrence  of  secondary  deposits,  uterine  cancer  does  not  occupy  that  excep- 
tional position  which  was  once  supposed,  but  that  it  presents  a  remarkable  simi- 
larity to  cancer  of  other  hollow  organs,  chiefly  composed  of  organic  muscular  fibre, 
as  the  oesophagus,  stomach,  and  intestines. 

2  See  p.  124. 

3  Recherches  sur  le  Traitement  Midicale  des  Tiimeurs  Cancereuses  du  Sein,  8vo. ,  1844, 
p.  258. 


INFLUENCE     OF    AGE     ON     ITS    PRODUCTION.  295 

tion  from  the  fact  that  out  of  5122  post-mortem  examinations  of 
both  sexes  in  the  hospitals  of  Prague,  Vienna,  and  Leipzig,  there 
were  441  of  cancer,  of  which  113  were  of  cancer  of  the  womb/ 

I  have  ah'cady  referred  more  than  once  to  the  circumstances 
which  render  the  statistics  of  a  hirgc  hospital  inconclusive  as 
evidence  of  the  comparative  frequency  of  diiferent  diseases.  The 
sufferings  that  generally  attend  cancer  in  some  of  its  stages,  and 
the  costly  nature  of  the  remedies  by  which  these  sufterinu-s  are 
best  assuaged,  induce  a  very  large  number  of  patients  afflicted 
with  that  disease  to  seek  relief  at  a  wealthy  institution  like  St. 
Bartholomew's  Hospital,  and  I  have  no  doubt  but  that  my  own 
experience  there  would,  without  allowing  for  these  causes,  lead 
me  to  suppose  cancer  of  the  womb  to  be  even  more  common  than 
is  actually  the  case.^  But  though  this  be  so,  the  disease  still  re- 
mains, of  all  organic  afiections  of  the  womb,  alike  the  most  fre^ 
quent  and  the  most  terrible. 

We  light  at  once  upon  surer  ground  if,  from  the  attempt  to 
determine  its  exact  frequency,  we  pass  to  the  inquiry  into  the  cir- 
cumstances that  favor  its  development;  the  influence  of  age,  of 
marriage,  childbearing,  &c.,  upon  its  production. 

Dr.  Walshe,^  whose  erudite  work  on  Cancer  will  alwa^'S  continue 
to  be,  with  reference  to  many  points,  the  best  authority  on  the 
subject  of  which  it  treats,  was  the  first  to  show  that  there  is  a 
progressive  increase  in  the  frequency  of  cancer  with  the  advance 
of  age.  I  hardly  need  observe  that  the  frequency  of  any  disease 
at  different  ages  can  be  rightly  estimated  only  by  a  comparison  of 
the  number  of  cases  in  which  it  occurs,  with  the  total  population 
at  the  same  age ;  though,  from  neglecting  this  obvious  condition, 
erroneous  conclusions  have  sometimes  been  drawn  with  reference 
to  this  and  other  similar  questions. 

Taking  the  population  of  England,  however,  at  decennial  pe- 
riods, it  seems,  and  Mr.  Paget's  researches  lead  to  the  same  result, 
that  with  every  ten  years  of  additional  age  after  the  age  of  twenty, 
the  liability  to  cancer  steadily  increases.  A  fjxct  this  of  great 
interest,  showing  how  a  disease  of  constitutional  degeneracy  grows 
more  and  more  common  with  the  enfeebling  of  the  powers  of  nu- 
trition, and  attains  its  greatest  frequency  when  nature's  alchemy 
has  well-nigh  reached  its  end,  and  the  power  to  transmute  the 
rough  material  into  the  highly  organized  and  wonderfully  com- 
plex tissues  of  the  body  is  almost  gone.  But  it  is  scarcely  less 
interesting  to  find  that  when  a  part  has  outlived  its  uses  it  often 
begins  to  die,  and  that  the  greatest  frequency  of  cancer  of  the 

1  Wagnor,  op.  cit.,  p.  2. 

2  Dr.  Lever,  on  Diieases  of  the  Uiet-iis,  8vo.,  London,  1848,  p  lfi5,  states  that 
among  the  out-patients  of  Guy's  Hospital,  the  proportion  of  cases  of  uterine 
cancer  to  other  uterine  diseases  was  nearly  as  1  in  7,  or  13.5  per  cent.  At  Barthol- 
omew's I  found  the  proportion  to  be  1  in  182  or  5.4  per  cent. ;  numbers  which  I 
mention  merely  as  showing  how  unsafe  it  would  be  to  draw  any  inferenci-s  as  to 
the  comparative  frequency  of  that,  or,  indeed,  of  any  other  disease,  from  such  data 
as  are  afforded  bv  the  out-patient  books  of  an  hospital. 

3  Op.  cit.,  p.  140. 


296  INFLUENCE    OF    AGE,    AND     OF 

breast  and  of  the  womb  is  not  governed  by  the  same  law  as  pre- 
vails with  reference  to  the  disease  in  other  parts,  but  occurs  long 
before  the  ordinary  period  of  human  life  has  been  attained. 

"  The  age  of  most  frequent  occurrence  of  scirrhous  cancer  of 
the  breast,"  says  Mr.  Paget,^  "  is  between  forty-five  and  fifty  years. 
IN'early  all  records,  I  think,  agree  in  this.  The  disease  has  been 
seen  before  puberty,  but  it  is  extremely  rare  at  any  age  under 
twenty -five ;  after  this  age  it  increases  till  between  forty-five  and 
fifty,  and  then  decreases  in  frequency ;  but  at  no  later  age  becomes 
so  infrequent  as  it  is  before  twenty." 

This  statement,  too,  he  illustrates,  not  simply  by  tlie  absolute 
numbers  of  cases  which  he  has  collected,  but  likewise  by  com- 
parison with  the  population  at  diflerent  ages. 

Much  the  same  fiict  holds  good  with  reference  to  uterine  can- 
cer, as  is  shown  by  the  subjoined  table  of  the  ages,  of  the  patients 
in  595  cases,-  collected  from  various  sources. 

Actual  Number. 

Between  25  and  30  years, 39 

"        30    "    40     "  166 

"       40    "    50     "  242            , 

"       50    "    60     "  95 

"       60    "    70     "  48 

Above                  70     "  5 

595 

Though  the  period  of  a  woman's  life  exerts  so  great  an  influ- 
ence in  predisposing  to  cancer  of  the  womb,  it  yet  does  not  appear 
that  the  actual  cessation  of  the  menses  has  any  important  share  in 
calling  that  predisposition  into  activity.  In  six  out  of  eighteen  of 
Lebert's  cases,^  in  which  menstruation  had  alreadj^  ceased,  the 
commencement  of  the  disease  was  stated  to  coincide  with  the 
cessation  of  the  menses.  The  same  coincidence,  however,  was 
observed  only  in  three  out  of  thirty-nine  of  my  patients  in  whom 
menstruation  had  already  ceased.  In  two  even  of  these  the  s^^mp- 
toms  were  said  to  have  existed  for  eight  and  ten  years  resj^ectively, 
so  that  all  which  can  be  reasonably  alleged  concerning  them  is 
that  indicivtions  of  uterine  disease  bad  persisted  ever  since  the 
menstrual  crisis,  and  that  at  length  cancerous  disease  had  become 
developed.  In  one  case  the  first  symptom  of  cancer  appeared  within 
five  months,  in  another  within  .eight  months,  in  three  in  a  year, 
in  two  in  three  years,  and  in  the  remaining  thirty  at  periods  vary- 
ing from  three  and  a  half  to  twenty-nine  j-ears  from  the  cessation 
of  the  menses. 

The  antecedent  condition  of  the  patient's  uterine  functions,  as 

1  Op.  cit,  vol.  ii,  p.  324. 

2  Of  these  cases  170  are  from  my  own  notes;  the  remainder  are  collected  from 
Lebert,  Kiwisuh,  and  his  editor  Scanzoni,  from  Chiari,  and  from  Dr.  Hibley's 
"  Report  on  the  Statistics  of  Cancer  in  the  Middlesex  Hospital,"  in  vol.  xlii  of 
Medico-Chmirgical  Transactions.  I  purposely  do  not  include  the  often-quoted 
table  given  by  Madame  Boivin  (o;3.  cit.,  vol.  ii,  p.  9),  because  it  was  drawn  up  at  a 
time  other  diseases  were  not  infrequently  confounded  with  cancer,  and  that  her 
facts  are  vitiated  by  this  error  is  abundantly  evident. 

-3  Op.  cit.,  p.  275. 


PREVIOUS  STATE  OF  SEXUAL  FUNCTIONS.      297 

fiir  as  the  presence  or  absence  of  menstrual  disorder,  or  of  pre- 
vious disease  of  the  womb,  is  concerned,  is  not  without  interest 
from  the  negative  result  which  it  yields,  and  from  the  evidence 
thus  aflbrded,  if  farther  proof  of  the  fact  were  wanting,  that  no 
rehition  whatever  subsists  between  inflammatory  affections  of  the 
wonii)  and  the  subsequent  occurrence  of  cancer  of  the  organ. 

In  157  out  of  the  170  cases,  the  manner  in  which  the  menstrual 
function  was  usually  performed  was  made  the  subject  of  special 
iiupiiry.  In  131  cases  it  was  performed  in  all  respects  naturally, 
from  the  time  of  its  complete  establishment  until  the  commence- 
ment of  the  disease.  In  26  cases  it  was  either  habitually  or  fre- 
quently unnatural  in  some  respect  or  other,  viz. : 

In   1  scanty,  In  4  postponing, 
"  10  puinful,  "  4  iiTPgular, 

"    2  profuse,  "  1  anticipating. 

"    4  profuse  and  painful, 

If  the  inquiry  be  made  with  reference  to  the  first  establishment 
of  menstruation,  we  shall  as  little  find  anything  indicative  of  a 
special  connection  between  the  difficult  establishmentof  the  men- 
strual function  and  the  subsequent  development  of  cancer.  In 
117  out  of  146  cases,  menstruation  was  established  without  any 
untoward  symptom,  while  in  29  instances  its  first  occurrence  was 
attended  by  more  or  less  local  or  constitutional  suftering.  These 
numbers  yield  the  proportion  of  almost  exactly  20  per  cent,  of 
unfavorable  cases,  while  the  average  which  I  obtained  from  all 
patients  who  came  to  me  at  St.  Bartholomew's  Hospital  on  account 
of  uterine  ailments  was  22.7  per  cent,  of  unfavorable  cases;  and 
Mr.  Whitehead,  of  Manchester,  arrives  at  22.30  per  cent,  as  the 
proportion  of  unfavorable  cases  among  4000  women  not  suftering 
from  any  special  disorder  of  their  sexual  system. 

But  though  it  should  appear  that  in  these  cases  neither  the  first 
establishment  of  menstruation  nor  the  manner  of  its  ordinary  per- 
formance has  presented  any  striking  deviation  from  health,  it  may 
yet  be  supposed  that  we  shall  find  indications  of  previous  uterine 
disorder  (as  some  suppose  of  uterine  inflammation),  out  of  which 
the  cancerous  disease  has  been  subsequently  developed.  Evidence, 
however,  seems  to  be  directly  opposed  to  this  supposition,  for  in 
the  history  of  only  5  out  of  the  whole  170  cases  is  tliere  any  men- 
tion of  serious  uterine  ailment  previous  to  the  commencement  of 
the  cancer.  One  patient  had  had  a  polypus  removed  ten  years 
before,  two  stated  that  they  had  suffered  ever  since  their  last  con- 
finement, ten  years  before  in  the  one  instance,  and  three  in  the 
other,  from  symptoms  of  uterine  affection  ;  in  one  the  symptoms 
gradually  developed  themselves  out  of  tliose  of  uterine  inflamma- 
tion, and  in  the  fifth  out  of  those  of  pelvic  abscess  in  the  course 
of  two  years. 

Though  amj)le  proof  to  the  contrary  has  been  long  since  ad- 
duced, we  still  find  it  asserted  sometimes  that  single  women  and 
those  who  liave  had  no  children  are  most  liable  to  be  attacked  by 


298 


INFLUENCE     OF    FECUNDITY 


cancer.  The  truth  appears  to  be  the  direct  reverse  of  tliis  state- 
ment; for  out  of  168  cases  of  uterine  cancer,  there  were  but  3  in 
which  the  patients  were  sins^le  women,  and  only  13  in  which  they 
were  sterile.  In  other  words,  there  was  but  1  sterile  marriage  in 
every  13  of  the  cancer  patients,  while  the  general  average  among 
my  patients  at  St.  Bartholomew's  Hospital  was  1  sterile  marriage 
in  every  8.5.  Nor  is  this  all ;  but  the  further  we  carry  this  inquiry 
the  more  strikingly  does  it  appear,  not  that  sterility,  but  rather 
that  over-fecundity,  predisposes  to  uterine  cancer. 

As  already  stated,  only  13  out  of  165  married  women  affected 
with  cancer  were  sterile,  2  are  said  to  have  had  children,  but  their 
number  is  not  stated,  while  the  remaining  150  had  been  pregnant 
1046  times,  189  of  the  pregnancies  terminating  prematurely,  857 
at  the  full  period.  Or,  to  state  the  same  fact  somewhat  dilferently, 
there  was  an  average  of  6.8  pregnancies  to  each  fruitful  marriage, 
or  5.6  children  at  the  full  period,  and  1.2  abortions,  while  the 
number  of  children  per  marriage  in  this  country  generally  is  esti- 
mated at  4.2.' 

Some  of  these  points  will  perhaps  be  still  better  illustrated  by 
the  subjoined  table  : 


Number 

Pregnancies 

Number 

Children 

Number 

Abortions 

of  women. 

to  each. 

of  women. 

to  each. 

of  women. 

to  each. 

18      . 

.      .         1 

15      .      . 

.         1 

32     .     . 

.         1 

1")      . 

2 

K)     .     . 

2 

22     .     . 

.       2 

11      . 

.     .       3 

18     .     . 

.       3 

11     .     . 

.       3 

7     . 

.     .       4 

11     .     . 

.       4 

6     .     . 

.       4 

11     . 

.     .       5 

17     .     . 

5 

6     .     . 

.       5 

17     . 

.     .       6 

14     .     . 

.       6 

1     .     . 

.       7 

14     . 

.     .       7 

16     .     . 

.       7 

1     .     . 

.       8 

10     . 

.     .       8 

11     .     . 

.       8 

1     .     . 

.     11 

10     . 

.     .       9 

9     .     . 

.       9 

9     . 

.     .     10 

8     .     . 

.     10 

11     . 

.     .     11 

3     .     . 

.     11 

6     . 

.     .     12 

3     .     . 

.     12 

7     . 

.     .     13 

2     .     . 

.     13 

2 

.     .     14 

2     .     . 

.     14 

... 

2     '. 

.     .     16 

1     .     . 

.     17 

1     . 

.     .     17 

1     .     . 

.     18 

1     . 

.     .     18 

1     . 

.     .     19 

1     . 

.     .     20 

1     . 

.     .     24 

150 

148 

80 

The  table  explains  itself  sufficiently  to  render  comment  super- 
fluous.    One  only  fact  seems  worth  remarking  on — namely,  that 

1  It  is  almost  superfluous  to  adduce  further  evidence  of  this  fact.  Thu.s  Dr.  Sib- 
ley's Beporton  the  Statistics  of  Cancel-  gives  an  average  of  11  per  cent,  sterile  mar- 
riages, and  5.2  children  to  each  fruitful  marriage.  Scanzoni's  figures,  op,  cit.,  p. 
284,  yield  the  singular  result  of  7  children  to  each  fruitful  marriage,  but  at  the 
same  time  36  sterile  marriages  out  of  108. 


IN  PREDISPOSING  TO  CANCER. 


299 


there  were  but  2  out  of  the  whole  150  women  whose  pregnancy 
had  issued  merely  in  abortion. 

In  18  of  the  150  cases,  the  particulars  of  which  are  given  in  the 
annexed  table,  the  termination  of  the  patient's  pregnancy  occurred 
within  a  sufficiently  short  period  from  the  commencement  of  the 
symptoms  of  cancer  to  warrant  the  suspicion  that,  in  some  of 
tliem  at  least,  the  changes  of  the  puerperal  state  had  a  share  in 
calling  the  disease  into  activity. 


Number  of 

Number  of 

Number  of 

Issue  of  last 

Date  of  Symptoms  of 

Pregnancy. 

Children. 

Abortions. 

Pregnancy. 

Cancer. 

3 

3 

Live  Child. 

10  months. 

7 

6 

i 

II 

6         " 

12 

12 

II 

6         " 

10 

5 

5 

11 

4 

4 

3 

1 

(I 

Immediately. 

10 

7 

3 

II 

11 

9 

9 

II 

11 

2 

1 

i 

II 

II 

6 

2 

4 

II 

II 

7 

5 

2 

II 

II 

3 

2 

1 

Abortion  at 
4  months. 

1  month. 

11 

10 

1 

Ditto  at 
5th  month. 

Immediately. 

7 

6 

1 

Ditto  at 
2J  months. 

7 

4 

3 

Ditto  at 
3  montlis. 

6 

4 

2 

Ditto  at 
4  months. 

13 

9 

4 

Ditto  at 
4  months. 

10 

7 

3 

Ditto,  period 
not  stated. 

17 

13 

4 

Ditto,  ditto. 

All  of  these  patients  were  seen  by  me  within  fifteen  months, 
most  of  them  witliin  six  months  from  the  occurrence  of  abortion 
or  lal)or.  When  the  s^'mjitoms  are  stated,  as  in  thirteen  instances 
they  are,  to  have  come  on  immediately,  it  is  meant  that  there  was 
no  interval  of  health  between  the  patient's  delivery  or  miscarriage 
and  the  occurrence  of  hemorrhage,  or  of  some  well  marked  sj-mp- 
tom  of  cancer,  such  as  had  continued  in  each  case  to  characterize 
it  subsequently,  and  which  in  most  instances  was  present  at  the 
time  of  the  patient  coming  under  my  care. 

A  few  moments'  consideration  will,  I  think,  do  away  witli  any 
feeling  of  surprise  at  the  result  which  these  tables  show.  With 
old  age  comes  imperfect  and  perverted  nutrition,  and  with  it 
cancer  in  the  body  generall}^  increases  in  frequency.  Such  old 
age,  such  imperfect  nutrition*,  befall  the  womb  earlier  tlian  they 
do  other  organs,  and  cancer  becomes  developed  there  iiroi)ortion- 
ately  early.  With  each  successive  pregnancy  the  devel(>i)mcnt  of 
the  womb  is  less  and  less  perfectly  accomplished,  and  the  feeble 


300  SYMPTOMS     OF     UTERINE    CANCER: 

uterine  action  of  the  multipara,  the  greater  comparative  frequency 
of  hemorrhage  after  delivery,  and  even  of  rupture  of  the  uterus  in 
women  who  have  given  birth  to  several  children,  than  in  those 
who  are  in  labor  for  the  first  time,  are  but  so  many  different  illus- 
trations of  the  same  fact.  It  is  not  therefore  the  woman  who  has 
never  conceived,  hut  she  Avhose  uterus  has  oftenest  undergone  all 
the  changes  which  the  puerperal  state  brings  with  it, — the  fatty 
degeneration  of  its  fibres,  the  wasting  of  its  tissue,  the  most  pro- 
found disturbance  of  its  nutrition, — in  whom  this  disease  of  per- 
verted, imperfect  nutrition  is  most  frequent.  Nor  is  the  fact 
without  its  significance  as  illustrative  of  the  same  law,  that  in  18 
out  of  110  women  living  in  fruitful  marriage,  in  whom  cancer  of 
the  womb  came  on  before  the  fiftieth  year,  or,  in  other  words, 
before  the  period  of  sexual  vigor  was  passed,  the  very  moment  at 
which  the  important  changes  of  tlie  puerperal  state  were  going 
on,  the  very  time  when  the  nutrition  of  the  womb  was  most  dis- 
ordered, should  have  been  that  at  which,  one  might  almost  say 
out  of  which,  this  disease,  so  insidious  and  so  fatal,  was  developed. 

One  }»oint  still  remains  for  notice  with  reference  to  the  produc- 
tion of  cancer — namely,  the  infiuence  of  hereditary  predisposition 
in  favoring  its  development.  In  the  case  of  cancer  generall}',  the 
influence  of  constitutional  taint  has  been  ascertained  to  be  very 
real ;  nor  docs  it  appear  to  be  less  so  in  the  case  of  cancer  of  the 
womb,  though  the  number  of  observations  bearing  on  the  subject 
is  perha[)S  too  small  to  warrant  a  positive  opinion.  Of^  160  cases 
of  cancer  of  all  parts,  collected  by  Paget,'  2t),  or  1  in  6.1,  presented 
the  history  of  hereditary  cancerous  taint;  and  the  same  fact  was 
ascertained  with  reference  to  14  in  102,  or  1  in  7.2  of  the  cases 
referred  to  by  Lebert.^  Lebert  found  evidence  of  hereditary  ten- 
dency to  cancer  in  2  out  of  13  cases  of  cancer  of  the  womb;^  and 
it  existed  in  8  out  of  49  cases,  or  in  1  out  of  6.1,  in  which  I  made 
this  point  the  subject  of  inquiry.  In  1  of  the  8  cases  the  patient's 
father  had  died  of  cancer  of  the  throat ;  in  2  the  mother;  and  in 
4  the  sister  had  died  of  cancer  of  the  womb,  and  in  1  the  sister 
had  died  of  cancer  of  the  breast. 

There  are  three  symptoms  of  cancer  of  the  womb  so  almost  in- 
variable in  their  occurrence  that  the  merest  tyro  would  not  fail  to 
mention  them,  and  the  man  of  greatest  experience  would  still 
enumerate  them  as  its  grand  characteristics.  Pain,  and  hemor- 
rhage, and  vaginal  discharge  often  coexist  in  the  advanced  stages 
of  the  disease,  and  one  or  other  of  them  is  present  from  its  com- 
mencement, or  furnishes  us  at  least  with  the  first  evidence  of  its 
existence.  The  once  common  error,  however,  which  confounded 
under  the  name  of  scirrhus  a  variety  of  uterine  ailments  that  had 
no  real  relation  whatever  to  malignant  disease,  led  to  equally 
serious  misapprehension  of  the  import  of  these  symptoms.  Hemor- 
rhage was  supposed  to  be  the  invariable  evidence  of  ulceration 
having  occurred,  while   pain    and   constitutional   disorder,   and 

1  Op.  cit.,  vol.  ii,  p.  538.  2  Op.  cit.,  p.  134.  3  Ibid.,  p.  273. 


"  77 

u 

4f..3 

"  23 

l( 

1^.8 

"  15 

(( 

9.0 

PAIN.  301 

sundiy  forms  of  functional  tlisturbance,  both  of  the  womb  and  of 
adjacent  viscera,  were  imagined  to  characterize  tlie  first  or  so- 
called  scirrhous  stage  of  the  disease. 

In  166  cases  the  first  symptom  of  cancer  was  stated  by  the 
patient  to  have  been 

In  30  instances,  or  18.0  per  cent.,  pain  of  various  kinds,  and  of  various  degrees 

of  intensity. 
'  hemorrhat^e,  generally  profu.se,  without  pain. 

'  hemorrhage,  accompanied  by  jiain. 

'  pain    and    leucorrhoja,    or    watery  discharge, 

sometimes  offensive. 
"  21  "  12.6         "  leucorrhcea,  or  other  discharge  without  pain. 

Each  of  these  symptoms  deserves  a  more  careful  examination; 
and,  first,  with  reference  to  the  pain.  Both  at  tlie  commence- 
ment, and  through  the  whole  course  of  the  disease,  this  varies 
greatly  in  situation,  in  character,  and  in  intensity;  and  there  is 
no  one  kind  of  pain  which  can  be  regarded  as  peculiar  to  uterine 
cancer  in  any  stage  of  its  progress.  Under  the  term  pain,  too, 
must  be  included  various  uneas}^  sensations  experienced  during 
the  act  of  defecation  or  micturition,  the  result  sometimes  doubt- 
less of  the  disease  having  at  an  early  period  afi'ected  the  bladder 
or  the  bowel,  but  oftener  the  consequence  of  the  congested  state 
of  the  pelvic  vessels,  or  of  that  sympathy  between  the  womb  and 
other  pelvic  organs,  of  which,  in  the  course  of  all  uterine  ailments, 
one  meets  with  so  many  illustrations.  '  As  a  general  rule,  the 
pain  of  the  early  stage  of  cancer  is  not  severe;  it  is  by  no  means 
constantly'  referred  to  the  uterus,  but  is  more  often  s[)oken  of  as 
backache,  or  pain  in  the  loins,  wearying  by  its  constancy  rather 
than  by  its  severity.  "With  this  is  associated  in  some  instances  pain 
in  the  In-pogastrium,  usually  of  the  same  dull  character;  but  hyi)0- 
gastric  pain  alone,  and  unaccompanied  by  backache,  is  decidedly 
unusuah  Lancinating  pain,  decidedly  referred  to  the  uterus,  is 
not  common  at  an  early  stage  of  cancer,  neither  is  the  organ  in 
general  tender  to  the  touch,  and  in  not  a  few  instances  even  sexual 
intercourse  does  not  appear  to  be  attended  by  any  special  suffering. 
As  in  other  forms  of  uterine  disease,  pain  is  occasionally  referred 
to  one  or  other  iliac  region,  and,  like  ovarian  pain  in  general,  is 
marked  by  a  teiidency  to  exacerbation  in  paroxysms.  In  those 
cases  in  which  the  disease  sets  in  with  menorrhagia,  the  excessive 
loss  of  blood  is  often  accompanied  with  much  pain ;  but,  as  appears 
from  the  table,  the  majority  of  cases  of  hemorrhage  at  the  outset 
of* cancer  are  characterized  by  the  absence  of  pain;  while  the  ces- 
sation of  the  previously  profuse  bleeding  is  often  associated  with 
the  setting  in  of  juiin,  from  which  the  patient  was  }>reviously  free. 

With  the  advance  of  the  cancerous  disease,  pain  in  general 
increases  much  in  severity,  though  there  is  no  invariable  rule 
which  determines  either  the  amount  or  the  seat  of  the  chief  sufier- 
ing;  while,  in  by  far  the  greater  number  of  cases,  the  severest 
pain  is  experienced  long  before  the  patient's  death,  and  the  last 
months  of  existence,  when  all  the  evidences  of  the  cancerous 


302  CAUSES     OF    PAIN     IN     CANCER. 

cachexia  are  most  marked,  and  the  strength  is  daily  declining,  are 
happily  not  in  general  agonized  by  intensity  of  snfiering  such  as 
had  been  previously  endured.  The  causes,  however,  which  con- 
tribute up  to  a  certain  point  to  increase  the  patient's  sufterings  as 
her  disease  advances  are  many,  while  all  the  old  sources  of  distress 
continue.  Pain  referred  to  the  uterus  is  now  often  superadded  to 
the  former  pain  in  the  back  and  tlie  abdomen ;  and  this  pain, 
though  constant,  has  its  exacerbations,  in  which  it  becomes  utterly 
intolerable,  is  sometimes  described  as  a  burning  pain,  sometimes 
as  a  stabbing  pain  ;  while,  when  most  intense,  it  is  a  horrible 
agony,  which  can  be  likened  to  no  otlier  sufl'ering,  of  which  words 
seem  unable  to  convey  any  idea.  Every  night  generally  brings 
with  it  increase  of  suffering;  but  the  tits  of  the  sharpest  pain  are 
uncertain  in  their  occurrence,  and  appear  to  come  on  without  any 
exciting  cause.  Sometimes  the  severer  pain  precedes  an  outburst 
of  hemorrhage,  and  then  the  bleeding  gives  relief  for  a  time  ;  but 
in  many  instances  this  is  not  the  case.  Besides  the  old  h3'pogas- 
tric  pain,  from  which  the  patient  often  suiiers  in  the  earlier  stages 
of  this  disease,  there  are  now  frequent  attacks  of  circumscribed 
abdominal  pain  and  tenderness,  indicative  of  the  peritoneum 
covering  the  pelvic  organs  having  been  attacked  by  inflamma- 
tion, and  such  inflammation  comes  and  goes  several  times  in  the 
course  of  the  disease.  The  advance  of  the  disease  from  the  uterus 
itself,  along  the  walls  of  the  vagina,  adds  much  to  the  patient's 
sufterings,  and  does  so  especially  when  the  anterior  vaginal  wall 
is  thus  aftected.  In  this  case  the  infiltration  of  cancer  into  the 
tissues  at  the  upper  part  of  the  vagina  interferes  with  the  return 
of  blood  from  parts  quite  uninvolved  in  the  disease.  Hence  the 
great  swelling  of  the  urethra,  which  may  oftoi  be  felt  of  the  size 
of  two  thumbs  all  the  way  from  the  symphysis  pubis  to  the  bladder, 
and  hence  in  a  measure  the  frequent  desire  to  pass  water,  the  diffi- 
culty in  voiding  it,  and  the  occasional  inability  to  retain  it,  which 
so  greatly  harass  patients  with  cancer  in  the  womb.  But  other 
causes  besides  tend  to  aggravate  this  symptom.  It  is,  as  we  saw 
when  studying  the  morbid  anatomy  of  cancer  of  the  womb,  by  no 
means  unusual  for  the  bladder,  independent  of  the  extension  to  it 
of  malignant  disease,  to  be  the  seat  of  intense  congestion,  or  of 
inflammation  going  on  to  the  deposit  of  lymph  on  its  rugre,  or  to 
actual  ulceration  of  its  mucous  membrane.  Moreover,  the  ex- 
tension of  cancer  from  the  uterus  or  vagina  into  the  bladder  is 
usually  accompanied  by  much  severer  sufiering  than  is  experi- 
enced in  primary  malignant  disease  of  that  organ,  while,  whftn 
once  utero-  or  vagino-vesieal  fistula  has  been  formed,  sufferings 
from  a  new  source  are  entailed  upon  the  patient.  In  some  in- 
stances, too,  when  there  is  much  deposit  of  cancerous  matter 
about  the  bladder,  one  or  other  ureter  is  obstructed,  though  not 
in  general  absolutely  closed,  and  it  becomes  much  dilated,  run- 
ning a  tortuous  instead  of  a  straight  course,  while  its  walls  are 
greatly  thickened  ;  and  the  kidney  itself,  owing  to  the  difficulty  in 
the  performance  of  its  functions,  and  in  the  escape  of  its  contents, 


PAIN    SOMETIMES    ABSENT.  303 

wastes,  its  glandular  strncture  almost  completely  disappearing,  its 
calicos  being  dilated  into  a  number  of  sacculi,  distended  by  a 
urinous  fluid.'  In  a  minor  degree,  tliis  occurrence  is  by  no  means 
unusual,  and  to  it  must,  I  tliink,  be  attributed  a  measure  of  tlie 
backache  and  of  the  dysuria  from  which  patients  with  uterine 
cancer  suft'er. 

And  now,  before  passing  to  the  examination  of  another  symp- 
tom, something  ouglit  to  be  said  with  reference  to  those  few  ex- 
ceptional cases  in  which  cancer  of  the  womb  runs  its  course 
entirely,  or  almost  entirely,  without  pain.  It  cannot  be  too  con- 
stantly borne  in  mind,  that  in  many  instances  the  three  grand 
s\'mptoms  of  cancer, — pain,  and  hemorrhage,  and  offensive  dis- 
charge,— are  not  present  at  the  same  time.  The  disease  often  sets 
in  with  hemorrhage,  and  often  while  the  bleeding  lasts  no  2)ain  is 
experienced,  nor  is  any  fetid  discharge  perceptible.  At  a  later 
stage  the  bleeding  ceases,  the  pain  then  becomes  severe,  and  the 
discharge  offensive,  and  continues  so  to  the  end,  though  the  pain 
frequently  subsides,  sometimes  altogether  ceases  long  before  the 
patient  dies.  Most  of  the  errors  in  the  diagnosis  of  uterine  cancer 
which  have  come  to  my  knowledge  have  arisen  fromforgetfulness 
of  this  tact;  and  the  absence  of  pain  or  of  fetor  of  the  discharge 
has  been  assumed  to  negative  the  possibility  of  cancer  in  spite  of 
the  clearest  evidence  afforded  by  vaginal  examination  of  its  ex- 
istence. It  is,  however,  a  very  rare  occurrence  indeed  for  pain  to 
be  absent  through  the  whole  course  of  cancer,  though  by  no 
means  uiiusualfor  the  disease  to  have  made  great  progress  befoie 
any  suffering  is  experienced.  Though  not  invariably,  yet  in  the 
majority  of  cases,  it  is  the  epithelial  variety  of  cancer  which  is 
distinguished  by  this  absence  of  pain.  Still,  in  some  of  the  soft 
varieties  of  medullary  cancer,  I  have  observed  the  same  thing. 
One  [)atient,  a  young  woman,  aged  thirty,  was  not  aware  of  the 
existence  of  any  serious  disease  until  a  profuse  discharge  of  blood 
took  place  on  one  occasion  during  sexual  intercourse;  and  1  knew 
another  who  imagined  herself  to  be  suffering  merely  from  menor- 
rhagia,  to  have  had  intercourse  with  her  husband,  and  not  to  have 
supi)osed  her  ailment  to  be  serious  till  abortion  at  the  sixth  week 
of  her  pregnancy  destroyed  her  by  the  hemorrhage  which  accom- 
panied it.  In  both  of  these  cases  the  disease  was  of  the  medul- 
lary kind.  The  most  remarkable  case,  however,  which  I  have 
met  with,  and  indeed  the  only  instance  in  which  no  pain  at  all 
-was  experienced,  was  that  of  a  woman  aged  thirtj',  who  had  men- 
struated irregularly  for  three  years,  though  without  any  sym[»toni 
of  local  ailment,  and  had  recovered  but  imperfectly  from  her  sixth 
labor  fourteen  months  before  she  came  under  my  notice.  Kleveu 
months  betbre  I  saw  her,  she  had  sudden  and  very  jiroiuse  hemor- 
rhage, which  continued  for  eight  weeks,  and  was  then  succeeded 

1  Si'f,  for  remarks  on  this  condition  of  the  kitlnoy,  Cruviilhior,  Ann/nniir  I'l/f/m- 
l'>f/i'/i'ij  vol.  ii,  p.  o70,  and  Atlas,  livraison  xxvii,  jil.  ii,  fig.  '2;  and  alst)  Wagner, 
oj>.  cii.,  p.  111. 


304  HEMORRHAGE 

by  abundant  transparent  non-offensive  discharge.  From  that  time 
until  her  reception  into  the  hospital,  the  hemorrhage  or  the  watery 
discharge  had  been  constantly  present,  and  the  patient  was  ad- 
mitted, in  a  state  of  extreme  exhaustion,  on  the  15th  of  July. 
Rest  and  astringents  checked  both  the  bleeding  and  the  discharge, 
and  food  and  wine  restored  her  strength  so  far,  that  on  the  ^Oth 
she  ^vent  home  to  arrange  some  domestic  matters,  but  on  my 
representation  of  the  serious  nature  of  her  disease,  she  returned 
on  the  5th  of  August.  Hemorrhage  recurred  the  next  day,  and 
continued  for  ten  days,  but  on  the  21st  she  was  so  far  recovered, 
and  had  regained  so  much  strength,  that  all  my  persuasions  to 
induce  her  to  remain  were  inefiectual.  She  went  home;  on  the 
1st  of  September  hemorrhage  returned,  and  of  this  she  died  on 
the  5th,  having  throughout  had  no  other  sense  of  discomfort  than 
some  diliiculty  iu  micturition,  from  which  she  had  suffered  for  two 
years,  and  which  was  not  at  all  increased  in  severity  by  the  super- 
vention of  the  cancerous  disease. 

jS'cxt  on  the  list  of  symptoms  stands  hemorrhage  ;  and  contrary 
to  what  is  still  laid  down  in  some  books,  bleeding,  so  far  from 
being  a  proof  that  the  disease  has  reached  the  stage  of  ulceration, 
is  often  the  earliest  sign  of  its  existence,  since  it  is  mentioned  in 
forty-six  per  cent,  of  the  cases  as  preceding  any  other  ailment.  A 
simihir  error,  as  you  scarcely  need  to  be  reminded,  was  once  gen- 
erally current  with  reference  to  hemorrhage  from  the  lungs  in 
phthisis.  The  haemoptysis,  Avhich  we  know  to  be  in  many  instances 
due  to  congestion  of  the  lung,  and  to  be  the  herald  of  coming  mis- 
chief, w^as  supposed  to  be  the  proof  of  irremediable  injury  already 
inflicted,  of  the  giving  way  of  a  vessel  in  consequence  of  its  being 
involved  in  the  spread  of  the  ulceration.  The  same  explanation 
as  accounts  for  the  bleeding  in  the  one  case  may  be  admitted  as 
interpreting  it  in  the  other;  ajid  the  practical  inference  to  be 
drawn  from  this  fact,  concerns  the  extreme  importance  to  be  at- 
tached to  causeless  hemorrhage  from  the  w^omb,  the  urgent  need 
for  making  a  vaginal  examination  by  which  we  may  detect  some 
forms  at  least  of  malignant  disease,  at  or  near  their  outset,  at  a 
time  wdien  remedies  can  retard  their  progress,  when  surgery  may 
perliaps  altogether  remove  them. 

Ilospital  practice  gives  so  little  opportunity  for  tracing  cases  of 
chronic  disease  from  their  commencement  to  their  close,  that  I 
can  give  no  definite  statement  as  to  the  general  relations  borne  by 
hemorrhage  to  the  other  symptoms  of  cancer  throughout  its  whole 
course.  The  form  in  which  the  bleeding  first  shows  itself  is  very 
various.  Sometimes  it  is  a  draining  of  blood,  not  profuse  but 
continuous,  resembling  the  discharge  at  an  ordinary  menstrual 
period,  except  that  it  may  not  have  come  on  at  the  right  epoch, 
and  that  it  generally  continues  for  a  longer  time,  until  it  excites 
anxiety  by  its  persistence,  or  in  other  instances  by  the  frequency 
of  its  return.  It  sometimes  assumes  these  characters  in  the  aged, 
in  whom  all  the  sexual  functions  have  long  ceased,  but  wdio  at  first 
regard  the  reappearance  of  a  sanguineous  discharge  with  a  sort  of 


IN     UTERINE     CANCER.  305 

half  complacency,  as  though  it  were  an  evidence  of  their  rejuven- 
escence ;  but  it  is  not  in  the  aged  alone  that  this  form  of  hemor- 
rhage takes  place.  It  is,  however,  more  common  for  hemorrhage 
to  take  place  either  at  a  menstrual  period,  or  a  day  or  two  after  its 
cessation  ;  but  though  an  ill-marked  periodicity  is  generally  ob- 
servable in  all  hemorrhages  from  the  womb,  whatever  be  their 
cause,  and  whatever  the  age  of  the  patient  in  whom  they  occur,  it 
is  certainly  unusual  for  menstruation  in  cases  of  cancer  to  con- 
tinue regular  in  its  return.  Sometimes  menstruation  anticipates, 
at  other  times  there  is  a  fortnightly  hemorrhage,  the  dischai-ge  at 
each  period  presenting  an  equal  claim  to  be  regarded  as  menstrual; 
but  it  is  not  often  that  the  proper  period  continues  to  be  recogniz- 
able after  two  or  three  returns  of  bleeding.  A  few  cases  occair  of 
a  single  profuse  outburst  of  blood,  not  followed  by  any  return  of 
hemorrhage,  or  merely  by  the  occasional  admixture  of  sanguineous 
fluid  with  tlje  discharge  which  takes  place  at  other  times.  Pro- 
fuse lochial  discharges  have  once  or  twice  passed,  according  to  the 
patient's  statement,  into  a  hemorrhage  which  has  been  the  first 
evidence  of  cancerous  disease ;  but,  of  course,  the  cases  in  which 
this  is  observed  are  rare  and  exceptional. 

In  the  early  stages  of  cancer,  the  bleeding  is,  as  tlie  table  shows,* 
most  frequently  unaccompanied  by  pain,  though  to  this  there  are 
some  exceptions.  With  the  advance  of  the  disease,  pain  is  gen- 
erally associated  with  the  hemorrhage  ;  for  with  the  exception  of 
cases  of  epithelial  cancer,  in  which  the  delicate  vessels  give  way 
under  the  slightest  cause,  congestion  of  the  womb  generally  pre- 
cedes each  outburst  of  bleeding,  and  is  relieved  b}^  its  occurrence. 
The  source  of  the  hemorrhage  continues  to  be  the  same  after  ul- 
ceration has  taken  place  as  it  Avas  before,  and  the  blood  is  furnished 
much  less  by  the  diseased  surface  than  by  the  whole  mucous  mem- 
brane of  the  womb.  The  expulsive  uterine  pains  which  in  many 
instances  accompany  the  hemorrhage,  are  due  to  the  same  cause 
as  in  ordinary  menorrhagia — namely,  the  formation  of  coagula 
within  the  cavity  of  the  womb,  and  the  eflbrts  of  the  womb  to 
exjicl  them  ;  efforts  which  are  all  the  more  painful,  owing  to  the 
resistance  which  they  encounter  from  the  unyielding  tissues  infil- 
trated with  cancerous  matter.  There  is  no  strongerevidence  that 
the  ulcerated  surface  furnishes  but  a  small  part  of  the  bleeding 
tlian  is  afibrdcd  by  its  invariable  diminution,  often  by  its  complete 
cessation  in  the  advanced  stages  of  cancer,  while  in  not  a  few  in- 
stances in  wliich  the  process  of  ulceration  has  l)een  most  raj)id. 
and  the  destruction  of  tissues  most  extensive,  there  has  been  but 
little  bleeding,  or  the  hemorrhage  has  been  entirely  confined  to 
the  outset  of  the  disease.  A  woman,  aged  thirty-eight,  came  into 
St.  Bartholomew's  Hospital  to  die  of  cancer  of  the  womb,  and 
sank  on  the  second  day  after  her  admission.  The  jiosterior  lip  of 
her  uterus  was  comitletely  destroyed,  and  the  finger  i»assed  up  at 
once  into  its  cavity,  whence  there  projected  an  irregular,  spiouting 

1  See  p.  301. 
20 


306  HEMORRHAGE    AND    DISCHARGE 

growth.  The  anterior  lip  of  the  uterus  was  firmly  adherent  to  the 
anterior  vaginal  wall,  along  which  the  cancerous  disease  had  ex- 
tended to  within  an  inch  of  the  vulva,  while  the  lip  itself  was 
irregular,  thickened,  and  in  great  measure  destroyed  by  ulcera- 
tion. A  single  attack  of  hemorrhage  lasting  for  five  hours,  was 
the  index  of  the  commencement  of  her  illness  eight  months  be- 
fore. Abundant  and  often  fetid  leucorrhoea  had  been  present  for 
many  months,  but  no  blood  appeared  at  any  time  in  the  discharge, 
except  on  the  single  occasion  which  I  have  mentioned. 

Lastly,  with  reference  to  the  discharges  in  cancer  cases.  They 
difier  much  in  different  forms  as  well  as  in  different  stages  of  the 
disease.  An  increased  mucous,  or  muco-purulent  discharge,  is  by 
no  means  uncommon  in  the  early  stages  of  medullary  cancer,  de- 
pendent on  the  general  congestion  of  the  womb,  which,  as  we 
have  seen,  accompanies  the  disease  at  its  outset.  This  discharge 
is  not  in  general  offensive,  but  sometimes  patients  will  complain 
of  an  offensive  discharge  as  having  been  the  first  symptom  of  the 
disorder,  and  this  in  cases  where  it  cannot  be  doubted  but  that  no 
breach  of  surface  at  the  time  existed.  In  this,  however,  there  is 
nothing  remarkable;  offensive  leucorrhoea  accompanies  uterine 
congestion  and  uterine  inflammation  in  many  instances,  or  results 
in  cases  of  mcnorrhagia,  or  of  polypus,  or  of  fibrous  tumor,  from 
the  decomposition  of  blood  which  has  been  poured  out ;  and  our 
patients,  at  any  rate,  are  not  to  be  expected  to  discriminate  be- 
tween bad  odors  from  one  cause  or  from  another.  With  the  ad- 
vance of  the  mischief  the  discharge  becomes  almost  always  un- 
mistakably offensive,  though  the  variations  in  this  respect  are 
even  in  the  same  case  not  a  little  remarkable.  It  has  been  seen 
that  portions  of  the  diseased  structure  not  infrequently  slough  off", 
and  are  detached  from  time  to  time,  leaving  behind,  when  they 
are  separated,  a  comparatively  clean  surface,  on  which  for  a  time 
a,  sort  of  attempt  at  healthy  granulation  may  be  perceptible. 
While  the  tissues  are  dying  and  being  renewed,  the  discharge 
from  the  cancer  will  generally  be  a  dirty,  highly  offensive  sanies  ; 
after  they  have  been  completely  thrown  off"  the  secretion  may  be 
but  scanty,  puriform,  and  comparatively  inoffensive;  while  in 
almost  every  case,  supposing  proper  precaution  to  be  taken  by 
syringing  the  vagina,  and  by  due  attention  to  cleanliness  to  re- 
move the  secretion  completely  and  frequently,  the  offensiveness 
of  the  discharge  will  depend  in  very  great  measure  on  the  activity 
with  which  the  processes  of  sloughing  and  separation  of  portions 
of  the  cancerous  substance  are  going  on.  When  the  disease  is  in 
a  comparatively  indolent  state,  as  it  sometimes  continues  for 
months  before  the  death  of  the  patient,  who  sinks  in  that  case 
under  the  cancerous  cachexia  rather  than  under  the  advance  of 
the  local  mischief,  the  discharge  is  often  neither  very  profuse  nor 
very  offensive.  In  the  indolent  state  of  the  disease,  too,  the  se- 
cretion has  seldom  anything  of  the  purulent  character  which  is 
observable  when  ulceration  and  its  allied  processes  are  going  on 
actively,  but  is  usually  watery,  sometimes  blood-stained,  at  other 


IN    UTERINE     CANCER.  307 

times  comparatively  transparent.  In  epithelial  cancer,  also,  the 
discharge  is  generally  serous,  and  often  almost  inodorous,  it  being 
rather  a  secretion  from  the  surface  than  the  result  of  any  decom- 
position and  destruction  of  tissue.  This  same  absence  of  any 
marked  offensive  odor  continues  likewise  very  frequent!}'  even 
after  ulceration  and  destruction  of  substance  have  commenced  in 
an  epithelial  cancer,  though,  as  its  characters  become  merged,  as 
they  often  do,  in  those  of  medullary  cancer,  the  discharge  almost 
always  acquires  a  much  worse  smell  than  before.  In  cases  ap- 
proaching to  cauliflower  excrescence,  where  the  patient  dies  of 
hemorrhage,  and  also  in  cases  of  the  so-called  corroding  ulcer  of 
the  OS,  the  discharge  continues  inofi'ensive  even  to  the  last.  These, 
however,  are  exceptional  cases,  and  in  no  way  interfere  with  the 
correctness  of  the  general  rule,  that  offensive  discharge  is  one  of 
the  symptoms  of  malignant  disease  scarcely  ever  absent  in  some 
part  of  its  course. 

One  or  two  |)ractical  inferences  may  be  drawn  from  what  has 
been  stated,  which  it  will  be  worth  while  always  to  bear  in  mind. 
First  of  all,  the  presence  or  absence  of  offensive  discharge  must 
in  no  measure  be  allowed  to  influence  us  in  deciding  on  the  ma- 
lignancy or  non-malignancy  of  any  disease  of  the  womb.  Mere 
irritation  of  the  organ  from  inflammation  or  congestion  may  be 
associated  with  it,  decomposition  of  blood  within  the  sexual  organs 
may  occasion  it,  or  the  decay  and  disintegration  of  a  fibrous  tumor 
or  polypus.  On  the  other  hand,  the  discharge  from  an  epithelial 
cancer  is  often  for  a  long  time  inoffensive,  and  sometimes  continues 
so  throughout,  while  in  other  cases  the  presence  or  absence  of  an 
offensive  character  in  the  secretion,  may  depend  upon  whether  the 
disease  is  in  an  indolent  or  in  an  active  state.  Even  in  the  latter 
case,  if  an  examination  be  made  just  after  the  dead  tissues  have 
been  thrown  off*  it  may  be  found  that  no  bad  smell  is  given  out 
by  discharges  which  but  a  lew  weeks  before  were  intolerably 
offensive. 

It  would,  I  apprehend,  answer  no  really  useful  end  were  I  to 
endeavor  to  group  together  those  symptoms  which  we  have  hith- 
erto examined,  and  out  of  them  to  form  a  general  portraiture  of 
uterine  cancer.  The  degree  in  which  each  symptom  is  manitested, 
the  order  in  which  the  symptoms  succeed  each  other,  the  time 
during  which  they  are  associated,  the  increase  of  one  and  the 
diminished  urgency  of  another,  all  vary  so  much  in  different  in- 
staDces  that  no  general  description  could  be  applicable  in  all  its 
details,  and  I  therefore  forbear  from  an  attempt  which  might  mis- 
lead, and  could  scarcely  instruct  you. 

Hitherto,  however,  no  mention  has  been  made  of  the  signs  of 
general  constitutional  disorder  which  sooner  or  later  manifeet 
themselves  in  almost  every  case  of  cancer,  whether  of  the  wondj 
or  of  other  organs,  and  which  add  much  to  the  patient's  distress. 
The  cancerous  cachexia,  v.'hich  is  absent  only  in  some  few  in- 
stances of  epithelial  carcinoma  where  death  takes  }i1ace  from  pure 
loss  of  blood,  is  something  more  than  the  mere  antemia  produced 


308  CANCEROUS  CACHEXIA. 

by  bemorrliage,  or  by  tbe  exhaustion  that  follows  long-protracted 
suffering.  "The  fount  of  all  the  blood  is  touched  corruptedly  ;" 
food  does  not  nourish,  the  strength  fails,  the  body  wastes,  the 
stomach  refuses  to  perform  its  proper  functions;  nausea  distresses 
the  patient,  or  sickness  wears  her,  and  the  red,  raw,  glazed,  or 
aphthous  tongue  indicates  bat  too  clearly  the  state  of  the  digestive 
mucous  membrane,  and  explains  the  urgency  of  that  thirst  which 
drink  cannot  quench,  which  it  is  so  often  scarcely  able  even  for  a 
few  moments  to  allay.  The  state  of  the  bowels  is  frequently  an 
additional  source  of  trouble,  constipation  alternating  with  diarrhoea. 
The  former  condition  is  frequently  induced  in  measure  by  the 
mechanical  obstacle  which  the  enlarged  and  hardened  womb  offers 
by  its  pressure  on  the  rectum  to  the  passage  of  the  faeces,  and  is 
still  further  maintained  by  the  lack  of  muscular  power  in  the  in- 
testines themselves,  which  are  no  longer  able  by  vigorous  peristaltic 
movements  to  propel  their  contents.  When  once  diarrhani  comes 
on,  the  same  want  of  power  allows  it  to  continue  till  the  intestinal 
canal  is  completely  emptied,  while  to  the  same  cause  may  be  in  a 
large  measure  attributed  the  flatulence  which  often  distresses  the 
patient,  producing  much  abdominal  pain,  and  not  infrequently 
issuing  in  an  attack  of  diarrhoea.  The  sleep  is  always  disturbed 
and  unrefreshing;  opiates  indeed  may  relieve  the  pain,  but  they 
often  aggravate  the  other  ailments;  the  patient  feels  too  ill  to 
sleep,  or  if  she  dozes,  the  parched  mouth  and  burning  throat  awake 
her,  or  else  the  sense  of  utter  prostration  and  exhaustion,  and  the 
sufferer  returns  to  consciousness  with  the  feeling  that  but  a  little 
more,  and  the  sleep  would  have  ended,  as  indeed  it  does  not  very 
rarely,  in  death.  In  this  state  I  have  on  five  occasions  known 
convulsions  to  come  on,  which  ended  in  coma,  and  in  three  of  the 
cases  the  coma  ended  in  death,  which  took  place  twice  in  twenty- 
four  hours,  and  once  at  the  end  of  eight  days.  These  head  symp- 
toms, however,  are  not  by  any  means  indicative  of  actual  disease 
of  the  brain,  for  two  of  the  patients  being  examined  after  death, 
no  trace  of  miscliief  was  discoverable  there  ;  and  two  others  having 
rallied  from  the  convulsions,  lived  for  many  months,  while  the 
hemiplegia  which  in  one  instance  had  followed  the  fits  disa[)[)cared 
by  degrees,  but  completely.  In  a  sixth  case  great  impairment  of 
sensibility  of  the  left  side  occurred  causelessly,  and  disappeared  in 
the  course  of  a  few  days,  a  month  before  the  death  of  the  patient, 
during  whose  illness  no  other  sign  of  cerebral  disturbance  was 
observed.  The  cause  of  these  cerebral  symptoms  is  obscure.  The 
only  explanation  of  tlieni  with  which  lam  acquainted  is  that  sug- 
gested b}^  AI.  Aran,^  who  regards  them  as  dependent  on  hydrone- 
phrosis, and  the  consec^uent  abolition  of  the  function  of  the  kidney. 
I  do  not  know  how  far  the  recovery  for  a  season  of  patients  in 
whom  these  symptoms  have  occurred,  and  their  subsequent  death 
from  the  ordinary  progress  of  carcinoma,  may  be  fairly  regarded 
as  militating  against  this  theory.     In  two  instances  of  extreme 

1  Op.  cit,  p.  968. 


CANCEROUS  CACHEXIA.  309 

hydronephrosis,  produced  by  tlie  pressure  of  the  cancerous  womb 
on  the  uterus,  no  sign  of  head-disturbance  preceded  death;  and  in 
the  two  who  died  there  is  no  account  of  remarkable  hydronephrosis 
having  been  discovered  at  the  post-mortem  examination. 

But  these  are  exceptional  cases,  and  death  is  not  in  general  pre- 
ceded by  any  marked  cerebral  symptoms.  The  powers  of  life  by 
degrees  wear  out,  the  local  mischief  often  remaining  for  weeks  or 
months  quite  stationary,  and  when  at  last  the  patient  dies,  it  may 
be  dithcult  to  say  why  death  came  just  when  it  did,  why,  with 
disease  so  far  advanced,  it  did  not  come  sooner,  or  why,  life  having 
lasted  so  long,  it  should  not  have  continued  still  for  a  few  days  or 
a  few  weeks  longer? 

In  one  case,  indeed,  the  general  poisoning  of  the  blood  gave  rise 
to  the  symptoms  of  py?emia  which  ushered  in  the  patient's  death, 
though,  singularl}^  enough,  previous  to  her  fatal  illness  the  signs  of 
the  cancerous  cachexia  had  been  by  no  means  extreme.  She  was 
fifty-six  years  old,  the  S3'mptoms  of  uterine  disease  liad  existed  for 
only  four  montlis,  and  the  mischief  was  so  almost  exclusively 
limited  to  the  uterine  cavity,  that  a  moment's  hesitation  had  been 
felt  as  to  whether  the  disease  was  really  of  a  malignant  character. 
At  the  time  of  her  admission  slight  feverish  symptoms  were  pres- 
ent, which  at  the  end  of  a  week  became  more  intense,  and  were 
associated  with  pain  in  the  upper  extremities  preciselj'  like  that 
of  rheumatism.  This  pain  continued,  though  it  did  not  increase 
in  severity,  but  the  fever  rapidly  assumed  a  typhoid  character, 
the  pulse  rose  to  140  in  the  minute,  the  tongue  became  dry,  and 
on  the  sixth  day  she  died. 

This  case,  indeed,  stands  alone  in  my  experience,  though  there 
is  a  great  difference  in  the  intensity  of  the  symptoms  of  cancerous 
cachexia  and  in  the  rapidity  of  their  course,  while  no  constant 
relation  appears  to  exist  between  the  amount  of  tlie  local  disease 
and  the  amount  of  constitutional  disorder.  When  most  rapid, 
liowever,  the  constitutional  symptoms  still  nearly  alwaj'S  continue 
of  a  passive  kind;  and  even  the  peritoneal  inllammation  which 
has  been  referred  to  as  a  not  infrequent  cause  of  hypogastric  pain, 
and  as  producing  adhesions  between  the  pelvic  viscera,  does  not 
seem  to  have  any  tendency  to  assume  an  active  character,  and  does 
not  materially  contribute  to  shorten  the  patient's  life.  The  diarrhoea 
often  has  this  tendency,  sometimes  assuming  a  dysenteric  charac- 
ter, and  being  found  after  death  associated  with  great  congestion 
of  the  rectum  and  lower  part  of  the  large  intestine,  and  great  en- 
largement of  the  solitary  glands.  It  is  very  unusual  for  great  local 
pain  to  attend  the  last  few  days  of  the  patient's  life,  and  in  the 
very  few  instances  in  which  I  have  ob^^erved  it,  it  was  associated 
with  the  development  of  cancerous  disease  in  the  abdomen,  and 
did  not  appear  to  be  attributable  to  the  affection  of  the  womb. 

Two  deviations  from  the  ordinary  course  of  cancer  must  be 
noticed  before  we  leave  the  subject  of  its  sym]itoms.  Kefercnce 
has  already  been  made  to  the  occasional  absence  of  one  or  other 
of  those  symptoms  which  are  usually  regarded  as  characteristic  of 


310  ACUTE    CANCER. 

tlie  disease.  But  there  are  also  occasional  instances  in  "whicli  not 
merely  one  customary  symptom  is  absent,  but  in  which  all  the 
symptoms  are  so  little  marked  as  to  throw  the  nature  of  the  disease 
completely  into  the  shade.  It  is  not  very  unusual  for  patients  to 
apply  for  the  cure  of  supposed  menorrhagia,  in  whom  examination 
ascertains  the  existence  of  far-advanced  cancer  of  the  womb;  but 
the  most  remarkable  case  of  the  latency  of  all  its  symptoms  which 
has  come  under  m^-own  notice  is  the  following:  A  woman,  aged 
forty-five,  who  was  following  the  occupation  of  a  cook,  came  to  me 
at  the  Middlesex  Hospital,  complaining  of  constipation,  and  of 
some  uneasiness  in  defecation,  which  she  attributed  to  piles.  She 
had  no  hemorrhage,  and  no  uterine  pain,  and  it  was  only  on  closely 
questioning  her  that  she  admitted  the  existence  of  slight  leucor- 
rhoea.  There  were  no  hemorrhoids,  nor  was  there  any  disease 
about  the  rectum,  but  the  uterus  was  large,  less  movable  than 
natural  in  the  pelvis,  its  anterior  lip  hard  and  nodulated,  its  pos- 
terior destroyed  by  ulceration.  For  more  than  three  months  she 
continued  to  come  backwards  and  forwards  to  me,  and  during  the 
whole  of  this  time  she  retained  her  place,  expressing  great  relief 
from  simple  aperient  medicines  which  I  had  prescribed  for  her.^ 

I  do  not  know  her  subsequent  history,  but  the  practical  infer- 
ence from  cases  such  as  these  is,  that  we  must  take  nothing  for 
granted,  that  a  very  little  warrants  suspicion,  and  I  may  add,  that 
we  must  not  place  im}ilicit  reliance  on  our  patients'  statements 
when  they  deny  the  existence  of  some  symptom  which  is  either 
known,  or  popularly  believed  to  be  of  evil  import.  They  earnestly 
desire  its  absence ;  they  will  not  allow  themselves  to  believe  in  the 
existence  of  what  they  so  intensely  dread.  • 

The  other  variety  of  cancer  is  an  acute  form  of  the  disease^  winch. 
I  believe  to  be  very  rare,  but  which  runs  its  course  with  much 
febrile  disturbance,  and  with  symptoms  of  an  active  character  such 
as  may  be  taken  by  the  superficial  observer  for  those  of  inflamma- 
tory mischief.  It  is  a  form  which  I  have  seen  only  in  ^oung 
persons,  and  soon  after  delivery  or  miscarriage.  In  one  instance, 
a  woman  who  had  miscarried  at  four  months,  and  had  had  a  single 
profuse  attack  of  hemorrhage  two  months  before  she  came  under 
my  notice,  was  received  into  the  hospital  in  a  state  of  profuse  sali- 
vation, in  consequence  of  mercury  given  her  for  the  cure  of  alleged 
uterine  inflammation.  The  disease,  of  which  she  soon  died,  was 
cancer  in  a  state  of  far-advanced  ulceration;  but  there  had  been  so 
much  febrile  disturbance  and  so  much  abdominal  pain  as  to  throw 
an  intelligent  practitioner  off  his  guard,  and  to  lead  him  to  neglect 
what  might  seem  the  very  obvious  duty  of  making  a  vaginal  ex- 
amination. Another  case  somewhat  of  the  same  kind  I  have  also 
seen,  in  which  the  disease  ran  its  course  in  three  months  and 
seventeen  days;  its  commencement  being  reckoned  from  the  date 
of  the  patient's  delivery,  previous  to  which  she  was  not  aware  of 
any  symptom  of  uterine  disease.     In  this  case  the  patient  died  in 

1  A  case  of  the  kind  is  related  by  Dr.  Simpson,  op.  cii.,  p.  190. 


LABOR  COMPLICATED  WITH  CANCER. 


311 


a  state  of  coma  wliioli  had  sncceeded  to  convulsions,  and  her  state, 
even  at  the  time  of  her  admission,  was  one  of  very  great  urgency. 
She,  however,  had  a  hot  skin,  and  a  furred  tongue,  and  a  rapid 
pulse,  with  considerable  abdominal  pain,  and  I  can  readily  con- 
ceive that  at  its  outset  these  symptoms  might,  as  in  the  other  case, 
have  led  into  error. 

We  have  already  seen  that  on  the  one  hand  the  presence  of  a 
disposition  to  cancer  does  not  interfere  at  all  with  a  woman's  fer- 
tility, and  on  the  other,  that  the  changes  that  succeed  to  childbirth 
seem  to  ftxvor  the  advance  of  the  disease.  It  now  remains  for  us 
to  look  at  the  influence  which  cancerous  disease  of  the  womb  exerts 
on  the  process  of  labor  itself,  when  ^  woman  so  afflicted  has  the 
misfortune  to  become  pregnant.  Tlie  evidence  of  statistics  bears 
out  fully  what  one  would  anticipate  to  find,  and  sliows  that  the 
rugged  and  thickened  os  uteri  dilates  slowly,  painfully,  and  imper- 
fectly ;  that  it  is  often  rent  during  the  parturient  efforts,  and  that 
formidable  hemorrhage  takes  plac«,  or  dangerous  inflammation 
succeeds  ;  and  that  sometimes  so  insurmountable  are  the  obstacles, 
that  the  child  cannot  pass  at  all,  and  tlic  mother  and  her  unborn 
babe  either  perish  together  during  the  parturient  efibrts,  or  that 
gestation  is  prolonged  far  beyond  its  ordinary  term,  and  that  death 
at  length  takes  place  without  any  decided  effort  having  been  made 
by  the  uterus  to  expel  its  contents.^ 

Table  showing  the  Result  of  Seventy-five  Cases  of  Cancer  of  the 
Neck  of  the  Womb  complicating  Labor. 


Died  in  or 

Recovered 

Authority. 

Total  Cases. 

very  poon 

from  the  effects 

after  I^abor. 

of  Labor. 

2   Puchclt,        ,      .      . 

31 

18 

13 

3  Oldham,      .     .     . 

5 

2 

3 

■•  Cormack,    .     . 

1 

1 

5  Simpson,     .     .     . 

2 

2 

4 

^  Arnott,  .... 

6 

2 

■^  Scanzoni,     .     .     . 

4 

4 

8  Dorrinirton,     .     . 

1 

1 

9  Kiwisch,      .     .     . 

4 

4 

'"  Menzies, 

20 

10 

10 

•I  Spiegelbcrg,     .     . 

1 

... 

1 

75 

41 

34 

1  As  in  Dr.  Monzios'  very  remarkable  ca.se  recorded  in  G/asr/ow  Midical  Joitrnal, 
vol.  i,  p   129.  July,  1853. 

'■^  De  Tiimorihun  in  Pe/vi,  &c.,  8vo.,  1840,  cap.  iii  and  iv. 

8  Lonilun  Journal  of  Medicine,  1851,  p.  204,  and  (tui/'h  Ilospifnl  Reports,  2d  ^orica, 
vol.  vii,  )).  427.  "  London  Joiirnnl  of  Miulicine,  1851,  p.  212. 

6  Op.  cit.,  p.  648.  6  jV(v/.  Chir.  Trans.,  vol.  xxxi,  p.  37. 

'  Lehrhnrh  der  Geburt.'i/iUlfe,  vol.  ii,  258. 

8  Prov.  Med.  Journal,  Oct.  7,  14,  21,  1843.  9  Op.  elf.,  vol.  i,  p.  540. 

'"  Menzies,  Inc..  cit.  In  Menzies'  table  of  27  cases  are  incliidcd  those  of  Dcnman, 
contained  in  Pnchelt's  table,  and  some  cases  of  Oldham  and  Simpson,  which  are 
separately  referred  to  by  me.     These  being  omitted.  2lt  cases  remain. 

"  Monatschrijtf.  Oeburisk.,  Feb.  1858,  vol.  xi,  p.  110. 


312 


DIAGNOSIS  OF  UTERINE  CANCER. 


In  Seventy-two  Cases  the  Fate  of  the  Children  is  mentioned. 


Authority. 

Total  Cases. 

Dead. 

Born  alive. 

Puchelt,      .      . 
Oldham,     .     . 
Cormack,   .     . 
Simpson,    .     . 
Arnott,  . 

30 
5 
1 
6 
2 
4 
1 
4 

18 
1 

19 
4 

2 
2  twins 
4 
1 
4 
11 

11 
1 

1 
4 

1 

"i 
1 

Scanzoni,    . 
Dorrino-ton,    . 
Kiwisch,     . 
3Ienzies, 
Spiegelberg,    . 

72 

47 

26 

Hereafter%ve  must  return  to  the  subject,  in  order  to  inquire  into 
tlie  means  wliicli  will  give  ns  the  greatest  chance  of  carrying  the 
mother  and  her  child  safgly  through  these  dangers.  For  the 
present,  it  is  enough  to  have  adverted  to  them,  and  to  have  shown 
their  nature  and  extent. 

In  the  foregoing  lectures  I  have  occasionally  noticed  the  main 
distinctions  between  innocent  and  malignant  diseases  of  the  womb, 
and  it  may  at  first  sight  appear  needless  to  enter  into  details  con- 
cerning the  diagnosis  of  uterine  cancer,  since  its  characteristics 
are  so  well-marked  as  seldom  to  leave  room  for  doubt,  or  to  allow 
the  possibility  of  error,  except  to  the  grossly  ignorant,  or  the  wil- 
fully careless. 

But  though  this  is  usually  the  case,  yet  it  does  sometimes 
happen  that  error  is  fallen  into  by  persons  who  can  neither  be 
charged  with  want  of  knowledge,  nor  with  want  of  care,  and  such 
error  most  frequentl}'  takes  the  form  of  regarding  an  innocent 
disease  as  one  of  malignant  character,  and  thus  entails  much 
needless  anxiet}^  on  the  patient 'and  her  friends.  At  a  time  when 
induration  of  tlie  cervix  uteri  was  commonly  supposed  to  be  due 
to  scirrhous  de[)Osit,  this  mistake  was  much  more  frequently  com- 
mitted than  it  is  at  the  present  day ;  but  even  now  the  practical 
error  survives,  as  is  its  wont,  the  pathological  blunder  in  which  it 
originated. 

Hence  it  becomes  by  no  means  superfluous  to  lay  it  down  as  a 
rule,  so  far  as  I  know  without  any  exception,  that  long-standing 
induration  and  hypertrophy  of  the  cervix  uteri,  with  or  without 
superficial  abrasion,  but  unaccompanied  by  thickening  of  the  roof 
of  the  vagina  and  by  diminished  mobility  of  the  uterus,  are  due  to 
chronic  inflammation,  not  to  cancerous  deposit. 

So  great  is  the  importance  of  distinguishing  between  these  two 
conditions,  that  it  may  be  worth  while,  even  at  the  risk  of  being 
tedious,  to  contrast  them  with  each  other  : 


DIAGNOSIS  OF  UTERINE  CANCER. 


313 


In  InflamiMatory  Induration. 

The  history  of  the  patient's  ailments 
generally  goes  back  for  a  period  of  several 
years,  and  her  symptoms  have  come  on 
gradually. 

A  tedious  labor,  or  an  imperfect  con- 
valescence from  labor  or  rniscarriiige,  is 
very  frequently  referred  to  as  the  com- 
mencement of  the  patient's  ailments. 

Pain  is  a  more  constant  and  an  earlier 
symptom  than  hemorrhage.  Menstrua- 
tion is  often  scanty  ;  hemorrhage,  if  it 
occurs,  observes  a  monthly  or  sometimes 
a  fortnightly  type,  is  very  seldom  per- 
sistent, and  is  almost  always  attended  by 
much  sutl'ering. 

The  cervix  uteri  is  always  tender,  often 
exquisitely  so;  the  mobility  of  the  uterus 
is  but  little  modified  ;  the  enlarged  lob- 
ules of  its  lips  radiate  from  the  orifice. 


Ulceration  of  the  os  uteri  is  eitlier  a 
sim])le  abrasion  of  the  epithelium,  or  a 
red  surface  of  a  finely  granular,  velvety 
texture,  sometimes  raised  a  little  above 
the  level  of  the  adjacent  part,  never  de- 
pressed beneath  it.  The  margins  of  the 
ulcerations  are  always  smooth  and  regu- 
lar, and  the  discharge  is  sometimes  puru- 
lent, oftcner  glairy,  occasionally  a  little 
blood-streaked,  hardly  ever  offensive, 
and  furnished  more  from  the  interior  of 
the  uterus  than  from  the  ulcerated  sui*- 
face. 


In  Uterine  Cancer. 

The  average  duration  of  cancer  does 
not  exceed  eighteen  months,  and  the  first 
symptoms  are  generally  sudden  in  their 
occurrence. 

Though  cancer  occasionally  develops 
itself  out  of  labor  or  miscarriage,  yet  such 
cases  are  so  rapid  in  their  course  as  to 
render  mistake  impossible. 

Hemorrhage  is  an  earlier,  and  in  the 
first  stages  usually  a  more  urgent  symp- 
tom tban  pain.  It  is  causeless,  sudden, 
often  persistent,  not  governed  by  the 
menstrual  type,  and  the  season  of  flood- 
ing is  generally  one  of  mitigated  suff"er- 
ing. 

The  cancerous  cervix  is  often  but  little 
sensitive  ;  the  mobility  of  the  uterus  is 
early  interfered  with  ;  the  enlarged  lob- 
ides  of  its  lips  are  irregular  in  their 
position,  and  not  divided  by  fissures  ra- 
diating from  the  orifice.  ' 

Cancerous  ulceration  is  never  a  simple 
abrasion,  but  either  a  sprouting,  coarsely 
granular  outgrowth  with  everted  edges, 
or  an  excavated  ulcer  with  a  dark  sur- 
face, and  jagged  margins;  often  partially 
covered  by  a  dark-grayish  slough.  The 
discharge,  which  is  furnished  from  the 
diseased  surface  rather  than  from  within 
the  uterus,  is  either  thick,  yellow,  puru- 
lent, highly  offensive,  or  thin,  serous, 
often  blood-stained,  never  transparent 
and  albuminous. 


Attention  to  these  distinctions  will,  I  believe,  suffice  almost  in- 
variably to  prevent  the  confounding  of  mere  chronic  induration 
and  hyi)ertrophy  of  the  uterus  with  nuilignant  disease.  I  have 
however,  met  with  two  instances  in  which  the  diagnosis  between 
the  two  conditions  was  extremely  difficult,  and  in  which  time  alone 
reYnoved  suspicions  that  had  appeared  but  too  well  founded. 
Both  of  these  cases  presented  considerable  resemblance  to  each 
other ;  and  the  symptoms,  which  came  on  in  both  some  mouths 
after  delivery,  were  probably  due  in  reality  to  a  condition  of  im- 
perfect involution  of  the  uterus.  In  both  instances  profuse  hemor- 
rhage burst  forth  suddenly,  endangering  the  patient's  life,  and 
being  in  one  case  restrained  only  by  the  use  of  the  plug.  The 
uterus  was  in  both  cases  greatly  enlarged,  its  lips  were  swollen 
and  everted  and  its  orifice  was  open,  so  that  its  condition  closely 
resembled  that  of  the  womb  affected  by  fungoid  cancer;  while  the 
serous  discharge  which  flowed  in  the  intervals  between  the  attacks 
of  hemorrhage  gave  out  that  offensive  odor  commonly  regarded 
as  almost  pathognomonic  of  malignant  disease.  The  nature  of 
the  case,  too,  was,  with  one  of  the  patients,  rendered  the  more 
doubtful  by  the  circumstance  that  she,  being  turned  forty  years  of 
age,  having  given  birth  to  her  last  child  eighteen  moiitlis  before, 
and  having  weaned  it  seven  months,  had  yet  had  no  return  of 


314  DIAGJSrOSIS    OF    UTERINE    CANCER. 

menstruation,  while  her  health  was  failing,  and  she  had  snfFered 
much  from  dull  lumbar  pains.  In  this  case,  which  I  had  frequent 
opportunities  of  watching,  the  hemorrhage  recurred  at  irregular 
intervals  for  between  two  and  three  months,  when  it  ceased,  leav- 
ing the  patient  completely,  exhausted.  Slowly  she  regained  her 
strength  ;  and  at  the  end  of  another  three  months  the  menses  re- 
turned naturall3\  After  having  twice  recurred  at  their  proper 
periods,  the  menses  once  more  disappeared ;  their  cessation,  how- 
ever, was  accompanied  by  the  signs,  not  of  disease,  but  of  preg- 
nancy, which  terminated  in.  the  birth  of  a  living  child  at  the 
seventh  month  of  utero-gestation.  Very  serious  hemorrhage  at- 
tended the  labor,  but  convalescence  was  uninterrupted,  and  no  sign 
of  cancerous  or  other  uterine  disease  has  reappeared,  though  the 
patient  has  now  entered  her  forty-ninth  year,  and  the  menses  are 
becoming  irregular  in  their  return,  preparatory  no  doubt  to  their 
final  cessation. 

In  this  instance  I  was  not  alone  in  the  unftivorable  opinion 
which  I  entertained  of  the  patient's  prospects;  but  looking  back 
upon  the  case,  now  that  time  has  corrected  my  judgment,  I  can 
recall  to  mind  that  there  was  a  uniformity  in  the  enlargement  of 
the  uterine  lips,  and  in  the  degree  of  their  hardness,  which  is  not 
usual  in  fungoid  cancer,  and  that  tliere  was  an  absence  of  that 
nodulated  character  which  is  generally  obvious  in  the  uterus 
affected  by  malignant  disease. 

Between  iibrous  tumors  of  the  uterus  and  malignant  disease  of 
the  organ,  a  vaginal  examination  usually  enables  us  readily  to  dis- 
criminate. Still  it  must  not  be  forgotten  that  in  those  compara- 
tively rare  cases  in  which  the  body  of  the  uterus  is  affected  by 
cancer  while  its  orifice  is  free  from  disease,  we  may  find  a  tumor 
perceptible  in  the  abdomen,  coupled  with  marked  increase  in  the 
dimensions  of  the  uterine  cavity,  and  sometimes  with  irregular 
thickening  in  the  substance  of  one  or  other  uterine  wall,  closely 
resembling  that  produced  by  the  presence  of  a  fibrous  tumor, 
while  sometimes  a  distinct  outgrowth  is  perceptible  through  the 
OS.  Our  diagnosis,  however,  will  usually  be  directed  aright,  by 
the  health  being  more  impaired,  and  the  local  suffering  more 
persistent  than  is  usual  in  a  case  of  fibrous  tumor;  by  the  loss  of 
mobility  of  the  uterus  being  more  considerable  than  even  its  in- 
creased size  would  account  tor;  and  by  the  extreme  vagueness  in 
the  outline  of  any  tumor  proceeding  from  the  uterine  walls. 

Reference  has  already  been  made'  to  the  possibility  of  mistaking 
a  fibrous  tumor  just  passing  through  the  os  uteri  for  cancerous 
disease  of  the  organ  ;  and  I  have  known  the  disintegrated  slough- 
ing surface  of  a  pedunculated  fibrous  tumor  or  polypus  hanging 
down  into  the  vagina  to  be  taken  for  advanced  ulcerated  carcinoma 
of  the  neck  of  the  womb.  Such  an  error,  however,  ought  not  to 
be  committed,  for  on  a  careful  examination,  the  absence  of  the  os 

1  See  p.  237. 


DURATION     OF     UTERINE    CANCER.  315 

uteri  from  the  lower  end  of  tlie  tumor,  its  oval  or  pyriform  sliape, 
its  smooth  and  uniform  surface  at  those  parts  which  are  not  in  a 
state  of  ulceration,  and  the  possibility  in  almost  every  instance  of 
reaching  one  or  other  lip  of  the  os,  if  the  finger  is  carried  high  up 
along  the  tumor,  will  reveal  the  real  nature  of  the  case. 

One  point  only  still  remains  to  be  noticed  in  order  to  complete 
our  history  of  cancer  of  the  womb,  and  that  refers  to  its  duration^ 
which  seems,  indeed,  to  be  shorter  instead  of  longer  than  that  of 
many  other  forms  of  the  same  disease. 

In  twenty-two  instances  I  was  able  to  fix  accurately  the  dura- 
tion of  uterine  cancer,  and  found  that  it  was — 

Under     4  months, in  1  case 

5       "        "  3  " 

"           6        "        «  1  <i 

"             9         "          .            .      .  i<  1  u 

"         12        "        .     .     .     .     !  "3  " 

Exactly  1  j-oar,       "  2  " 

13  months, i<  1  << 

Between  1  and  2    years,  ...  "  5  " 

"       2  —  2J        "...  "  2  " 

"       2^—3          "...  "  1  " 

Exactly  3|                   "...  "  1  " 

Said  to  be  5,  but  doubtful,    .     .  "  1  " 

22 
Average  duration,  17.3  months. 

The  average  of  thirty-nine  cases,  as  given  by  Lebert,'  is  sixteen 
months  and  a  fraction,  a  result  very  near  approaching  to  my  own, 
and  less  than  the  average  duration  of  all  forms  of  cancer,' which  is 
stated  by  the  same  authority  at  eighteen  months,  the  progress  of 
the  disease  being  slower  in  the  mammary  gland,  the  testis  in  the 
male,  the  eye,  the  bones,  the  lymphatics,  and  the  intestinal  canal ; 
though  even  in  the  breast  and  the  testis,  in  which  its  advance  is 
most  tard}'',  the  average  duration  of  the  disease  does  not  exceed 
three  years  and  a  half.^ 

In  the  next  Lecture  we  shall  pass  to  the  investigation — I  wish 
we  could  do  it  with  brighter  prospects — of  the  remedial  means, 
whether  medical  or  surgical,  by  which  we  may  hope  to  retard  the 
course,  to  alleviate  the  sufferings  of  cancer,  sometimes  to  obtain 
for  the  patient  a  brief  respite,  now  and  then,  perhaps,  to  accom- 
plish her  cure. 

1  Op.  cit,  p.  270.'  2  Ibid.,  p.  122. 


816  TREATMENT    OF    UTERINE    CANCER. 


LECTURE    XXI. 

MALIGNANT  Oil  CANCEEOUS  DISEASES  OF  THE  UTERUS. 

Treatment  ;  various  opinions  entertained  at  different  times  concerning  it. 

Palliative  Treatment;  of  the  heniorrliages,  of  tiie  pain,  of  the  discharges, 
managemont  of  the  general  health,  and  of  symptoms  of  cancerous  cachexia. 
Pregnancy  and  labor  complicated  with  cancer  ;  question  of  induction  of  prem- 
ature labor  ;  management  of  the  labor  itself. 

Curative  Treatment;  extirpation  of  the  whole  uterus;  results  of  the  operation, 
and  reasons  for  rejecting  it.  Excision  of  the  neck  of  the  womb;  errors  which 
brought  it  into  discredit;  cases  suited  for  it;  modes  of  performing  the  opera- 
tion ;  dangers  ;  that  of  hemorrhage  the  chief.  Comparative  advantages  of 
ligature  and  excision  considered. 

Other  means  supposed  to  be  remedial  ;  employment  of  cold,  of  caustics,  and  of  the 
actual  cautery  ;  observations  on  each. 

Very  numerous  have  been  the  fluctuations  of  opinion  with  ref- 
erence to  the  management  of  cancer  of  the  womb.  When  knowl- 
edge concerning  it  was  most  imperfect,  alleged  remedies  abounded, 
and  various  medicines  had  the  reputation  of  eliminating  the  cancer 
poison  from  the  sj'stem,  and,  acting  tlius  through  the  medium  of 
the  constitution,  of  removing  the  local  disease.  Xcxt  came  a 
period  of  adventurous  surgery,  of  attempts  to  root  out  the  whole 
evil,  over  which  it  became  evident  that  internal  means  had  but 
little  influence.  Soon,  however,  practitioners  were  attrighted  at 
the  difficulties  and  the  dangers  of  such  operations,  and  then  re- 
sorted to  a  combination  of  local  and  general  treatment,  and  believ- 
ing that  between  cancer  and  inflammatory  induration  there  was 
some  close  bond  of  affinity,  they  endeavored  by  depletion,  and  by 
other  means  calculated  to  retard  the  changes  which  inflammation 
produces,  to  keep  at  bay  the  advances  of  cancer.  An  attempt 
was  made,  too,  to  vindicate  to  surgery  its  share  iji  the  removal  of 
tliis  disease,  even  when  medicine  was  of  no  avail,  and  for  a  time 
the  amputation  of  the  scirrhous  neck  of  the  womb  was  vaunted 
as  a  mode  of  almost  infallibly  arresting  the  otherwise  inevitable 
danger.  Time  and  increased  knowledge,  however,  have  led  us 
to  unlearn  much  in  which  our  predecessors  had  an  unfaltering 
faith.  We  have  renounced  all  credence  in  the  specific  remedies 
once  believed  in  ;  we  have  abandoned,  as  too  hazardous  to  be  w'ar- 
rantable,  the  extirpation  of  the  whole  uterus  ;  we  have  found  out 
that  there  is  no  relation  bet\veen  inflammation  and  cancer ;  that 
antiphlogistic  means  which  remove  the  efiects  of  the  former,  have 
yet  no  powder  to  control  the  progress  of  the  latter ;  and,  moreover, 
that  the  supposed  triumphs  of  surgery  in  cutting  short  the  dis- 
ease, by  removing  that  small  part  oiP  the  organ  whence,  if  let 
alone,  it  might  have  spread  to  surrounding  tissues  and  neighbor- 
ing viscera,  were,  for  the  most  part,  purel}^  imaginary;  and  the 
trophies  once  displayed  in  our  museums  are  now  generally  put 


TREATMENT  OF  HEMORREAGE  IN  UTERINE  CANCER.   317 

out  of  siglit,  as  the  mementoes  of  a  pathological  bliintler  and  a 
needless  operation. 

It  seems,  then,  that  in  the  greater  number  of  instances,  our  duty, 
in  the  treatment  of  uterine  cancer^  is  the  very  humble  one  of  miti- 
gating sufferings  which  we  cannot  remove;  of  depriving  death  of 
some  of  its  terrors,  though  m'g  may  feel  ourselves  powerless  to  delay 
its  stei»s.  Carefully  to  study,  religiously  to  carry  out  this  duty, 
calls  for  much  care,  for  much  and  most  untiring  patience.  But 
there  are  some  few  cases  concerning  which  we  must  admit  the 
possibility  of  a  better  issue  being  attainable,  and  we  shall  advance 
all  the  more  steadily  in  our  quest  of  means  of  cure,  now  tliat  we 
have  learnt  with  greater  certainty  tlian  before  to  distinguish  the 
different  varieties  of  the  disease;  to  know  the  cases  in  which  re- 
covery may  be  possible,  from  those  in  which  we  shall  assuredly 
err  if  we  aim  to  do  more  than  palliate  the  more  urgent  symptoms. 

I  propose,  therefore,  first  to  jjass  in  review  the  diflerent  means 
by  which  we  can  minister  present  relief  to  the  patient  laborijig 
under  cancer  of  the  womb  ;  and  then  to  consider  the  exceptional 
cases  in  which  we  may  attempt  something  more,  and  the  merits 
of  the  various  proceedings  by  which  a  radical  cure  of  the  disease 
has  been  attempted,  has  sometimes  even  been  achieved. 

In  cases  of  cancer  generally,  our  attention  is  divided  between 
the  relief  of  the  local  symptoms,  and  the  maintenance,  as  far  as 
possible,  of  the  general  health.  I  know  of  no  means  by  which  the 
progress  of  cancer  can  be  arrested  in  its  first  stage,  and  the  disease 
ke[)t  stationary ;  a  source,  indeed,  of  constant  apprehension,  but 
the  occasion  of  little  present  discomfort,  and  of  no  immediate 
danger.  Almost  all  the  vegetable,  almost  all  the  mineral  poisons 
have  been  tried,  extolled,  and  rejected  in  turn;  tonics  have  been 
administered,  and  again  the  patient  has  been  [>laccd  under  the  so- 
called  hunger  cure — tliat  is  to  say,  her  food  has  been  reduced  to 
the  smallest  quantity  on  which  life  can  be  maintained;  and  this 
with  the  result  which  the  empirical  trial  of  remedies  almost  always 
merits,  almost  always  attains. 

The  hemorrltage  is  usually  the  first  symptom  which  so  excites 
the  patient's  alarm  as  to  induce  her  to  seek  for  medical  aid.  But 
unfortunately,  ere  then  the  disease  has  often  made  considerable 
advances,  and  its  nature  is  already  but  too  evident.  The  hemor- 
rhage at  the  outset  of  the  disease  being,  as  already  explained,  due 
to  congestion  of  the  womb,  our  first  endeavor  must  be  by  every 
means  to  abate  it,  and  thus  to  i)revent.  if  possible,  the  return  of 
the  l>leeding.  It  is  self-evident,  that  with  this  object  in  view,  every 
direct  excitement  of  the  sexual  organs  must  he  injurious,  and 
hence  there  can  be  no  exception  to  the  rule  which  interdicts  marital 
intercourse  whenever  there  is  the  least  suspicion  of  cancerous 
disease.  The  state  of  the  bowels  is  the  next  point  to  attend  to ;  and 
they  must  be  kept  freely  open,  if  possible,  by  mild  saline  aj)erients, 
which  unload  the  hemorrhoidal  vessels,  as  well  as  prevent  the 
accumulation  of  feces  in  the  intestinal  canal.  A  mild,  unstimu- 
lating  diet  is  equally  important,  and  I  have  no  doub^t  but  that  in 


318         TREATMENT  OF  THE  HEMORRHAGE. 

the  early  stage  of  cancer  an  opposite  plan  is  injurious  to  the  pa- 
tient's general  health,  and  indirectly  accelerates  the  advance  of 
the  disease.  "When  to  these  precautions  are  added  the  avoidance 
of  all  active  exertion,  and  the  most  absolute  rest  at  the  return  of 
each  menstrual  period,  I  fear  there  is  little  more  within  our  power. 
The  local  employment  of  depletion,  which  has  been  recommended 
in  the  early  stages  of  cancer,  is  very  rarely  admissible,  and  I  am 
not  disposed  to  advise  that  the  blood  should  ever  be  drawn  from 
the  uterus  itself,  but  rather  from  the  hypogastrium  or  the  groin, 
since  I  have  known  very  serious  difficulty  occur  in  arresting  the 
bleeding  from  leeches  applied  to  the  neck  of  the  womb  in  these 
cases. 

At  a  later  period  of  the  disease  the  hemorrhage  may  be  so  pro- 
fuse as  to  call  for  direct  restraint,  and  the  necessity  for  immediately 
checking  it  is  of  course  urgent  in  proportion  to  the  degree  of  anae- 
mia which  already  exists.  The  gallic  acid  is  of  all  astringents 
that  which  has  least  often  failed  me;  but  in  order  to  obtain  decided 
effects  from  it,  it  should  Ije  given  in  doses  of  six  or  eight  grains 
every  four  hours.  The  infusion  of  matico,  as  a  local  ai)plicati()n, 
is  also  of  much  use  in  some  of  these  cases;  but  the  numagemont 
of  the  injection  can  never  be  safely  intrusted  to  the  patient,  who 
either  employs  it  i n effect n ally,  or  else  causes  herself  much  suffering 
by  striking  the  neck  of  the  womb  in  her  endeavors  to  introduce 
the  instrument  far  enough  into  the  vagina.  There  are  obvious 
difficulties  in  the  way  of  plugging  the  vagina  in  cases  of  ulcerated 
carcinoma;  and,  indeed,  the  mode  in  which  the  profuse  bleedings 
usually  take  place,  by  sudden  outbursts  of  hemorrhage,  followed 
by  a  long  pause,  is  that  against  which  such  a  proceeding  is  least  of 
all  calculated  to  guard.  In  some  cases  of  soft  medullary  cancer, 
or  of  epithelial  cancer,  when  the  continuance  of  hemorrhage  be- 
comes a  very  serious  source  of  danger  to  the  patient,  we  may  break 
down  the  tissue  with  the  finger,  and  then  inject  into  the  midst  of 
it  the  tincture  of  the  sesquichloride  of  iron.  The  bleeding  vessels 
are  thus  destroyed,  and  the  coagulation  of  the  extravasated  blood 
by  the  chemical  agent  prevents  the  occurrence  of  any  further 
hemorrhage,  while  the  whole  mass  which  has  been  thus  treated 
sloughs  away  in  the  course  of  a  few  days,  leaving  behind  a  healthier 
surface,  or  one  at  any  rate  less  disposed  to  bleed.  This  proceeding, 
which  was  to  the  best  of  my  belief  first  recommended  by  Kiwisch,^ 
is  not  accompanied  by  much  pain,  nor  has  it,  in  my  experience, 
ever  been  followed  by  serious  constitutional  disturbance,  while 
the  improvement  which  for  a  time  succeeds  the  checking  of  the 
previous  drain  upon  the  system  is  often  very  remarkable.^    Kiwisch 

1  Op.  cit,  vol.  i,  p.  547. 

2  In  the  Lancet  for  December  29,  1855,  is  a  very  remarkable  case  related  by 
Dr.  Boulton,  of  Horncastle,  in  which  the  breaking  down  of  the  ti.ssue  of  a  large 
epithelial  cancer  of  the  cervix  uteri,  and  the  arrest  of  the  subsequent  bleeding  by 
caustics,  of  which  the  muriated  tincture  of  iron  appears  to  have  answered  best, 
had  been  persevered  in  for  five  years,  not  only  with  great  improvement  in  the 
patient's  condition,  but,  as  would  seem,  with  the  final  result  of  completely  destroying 
the  disease,  of  which  for  sixteen  months  previous  to  his  communication  the  os 


TREATMENT     OF    THE     PAIN.  319 

also  speaks  of  the  employment  of  the  actual  cautery  as  a  very  effi- 
cacious means  of  restraining  bleeding,  in  cases  where  the  surface 
is  of  too  firm  a  texture  to  be  broken  down.  I  have  not  tried  the 
actual  cautery  specially  for  this  purpose,  though  I  believe  that  in 
some  cases  of  uterine  cancer  I  have  obtained  by  it  much  tempo- 
rary improvement,  both  in  the  general  health  of  tlie  patient  and 
in  the  condition  of  the  ulcerated  surface.  Of  this,  however,  more 
hereafter. 

The  pain  is,  of  all  the  symptoms,  that  from  which  the  patient 
most  earnestly  prays  for  relief,  while,  unfortunately,  we  are  often 
but  little  able  to  afford  it.  There  is  a  permanent  pain,  or  at  least 
a  permanent  sense  of  discomfort,  which  most  women  ex[)erience, 
and  besides,  there  are  occasional  paroxysms  of  severe  suffering 
from  which  some  are  fortunately  exempt.  The  backache,  the 
pain  in  micturition,  and  the  distress  in  defecation,  are  usually  to 
be  relieved  rather  by  attention  to  the  functions  of  the  bladder, 
and  the  state  of  the  bowels,  than  by  direct  anodynes.  The  Vichy 
water  as  a  drink,  the  extract  and  decoction  of  uva  ursi,  with  small 
doses  of  liquor  potassa  and  tincture  of  henbane,  often  give  aiiuch 
relief  to  the  irritable  bhidder  which  troubles  the  patient  in  the 
early  stages  of  cancer,  while,  at  a  later  period,  when  organic  mis- 
chief has  commenced  there,  and  the  urine  is  loaded  with  i)ho8- 
phates,  small  doses  of  hydrochloric  acid,  with  the  extract  and 
decoction  of  pareira,  will  in  their  turn  be  of  service.  The  establish- 
ing a  habit  of  regular  action  of  the  bowels  will  save  the  })atient 
from  many  of  the  distressing  bearing  down  sensations  from  which 
she  had  previously  suffered.  Mild  laxatives,  such  as  the  confection 
of  senna,  or  very  small  doses  of  castor  oil,  are  generall}^  best  for 
this  purpose;  enemata  are  not  in  general  expedient,  for  their 
administration  is  often  very  painful,  owing  to  the  presence  of 
hemorrhoids,  while  the  pressure  of  the  distended  rectum  against 
the  womb  sometimes  brings  on  ver}-  /Severe  suiiering.  Plasters  of 
belladonna,  or  opium,  applied  to  the  back  or  above  the  pubes, 
sometimes  relieve  the  permanent  pain  in  those  situations,  while 
any  casual  aggravation  of  it  is  often  mitigated  by  the  local  appli- 
cation of  chloroform,  or  of  cotton-wool  soaked  in  a  liniment  of 
equal  parts  of  chloroform  and  oil,  ^nd  covered  over  with  oiled 
silk  to  prevent  evaporation. 

The  longer  the  patient  can  dispense  with  the  habitual  enqiloy- 
ment  of  anodynes,  the  better  is  it  for  her  general  health.  In  time, 
however,  they  are  sure  to  become  necessai'y,  and  the  need  for  them 
is  usually  first  experienced  at  night,  for  almost  always  at  that  time 
the  pain  becomes  more  severe  than  it  had  been  during  the  day. 
Whether  em[>loyed  at  night,  however,  or  given  more  frequently, 
it  is  always  desirable  to  begin  with  the  mildest  form  of  narcotic, 
and  to  pass  only  by  degrees,  and  as  each  in  turn  ceases  to  be  effi- 

utori  liad  prosontod  no  trace.  In  a  siibso<jiicnt  rrpDrt,  datml  OctolxT,  1807.  Mr. 
Honlton  adds,  tliat  after  tlic  lap.'ic  of  tlirt'c  years  from  the  last  o])eration  tlie  patient 
continued  pc!rfecti\-  well;  that  for  twelve  months  all  discharge  had  ceased,  and  that 
tiie  state  of  the  os  and  cervix  uteri  was  perfectly  normal. 


320  TREATMENT    OF    THE     PAIN. 

cacious,  to  those  which  are  more  potent,  and  to  the  preparations 
of  opium.  I  usually  begin  with  camphor  and  henbane  in  the 
form  of  pill,  giving  five  grains  of  each  at  bedtime,  and  find  in 
most  cases  that  henbane  is  a  more  certain  and  more  efiicient 
medicine  than  hemlock.  If  the  anodyne  begins  to  lose  its  power, 
it  is  not  always  necessary  at  once  to  increase  its  strength,  but  the 
same  dose  will  often  continue  to  act  if  it  be  combined  with  a 
draught  containing  ether,  or  some  other  diflhsible  stimulant. 
Twenty  minims  of  the  compound  spirits  of  ether,  and  fifteen  of 
the  chloric  ether,  will  often,  when  added  to  the  anodyne,  lull  the 
pain  which  had  previously  been  importunate,  or  procure  the  rest 
which  the  patient  had  before  been  unable  to  obtain.  Tbe  same 
fact  holds  good  through  tbe  wbole  course  of  the  disease,  even  at 
a  time  when  opiates  in  large  and  frequently  repeated  doses  have 
become  absolutely  necessary.  After  henbane,  I  generally  make 
trial  of  the  Indian  hemp,  for  though  it  is  an  uncertain  medicine, 
and  one  the  efl'ect  of  which  seems  to  be  much  modified  by  the 
idiosyncrasies  of  the  patient,  it  does  not  in  general  either  consti- 
pate or  produce  headache,  or  disorder  the  digestion  to  so  groat  an 
extent  as  opium.  Chlorodyne  has  also  many  of  these  advantages, 
and  though  perhaps  more  apt  to  constipate  than  the  Indian  hemp 
alone,  its  action  is  more  certain,  and  its  influence  less  speedily 
worn  out.  Belladonna  does  not  constipate,  but  it  occasions  head- 
ache, and  if  given  in  doses  sufficiently  large  to  control  the  pain  of 
cancer,  it  is  sometimes  followed  1)}'  an  ahirniing  degree  of  depres- 
sion. We  come  then  to  opium  and  its  different  prei)arations,  and 
of  all  of  these  the  tincture  is  generally  borne  for  the  longest  time, 
and  with  the  greatest  relief.  There  are  peculiarities  in  different 
cases,  however,  which  lead  us  sometimes  to  prefer  one  form  and 
sometimes  another  of  this  remedy.  The  black  drop,  I  think,  causes 
on  the  whole  less  sickness  tlian  the  other  preparations  of  opium, 
morphia  not  excepted,  while,  in  spite  of  the  man}'  recommenda- 
tions of  the  latter  medicine,  we  are  sometimes  compelled  to  abstain 
from  giving  it,  in  consequence  of  the  extent  to  which  it  aggravates 
the  irritability  of  the  skin,  and  the  disposition  to  urticaria,  which 
are  not  very  unusual  attendants  upon  uterine  cancer.  1  have  not 
found  any  such  advantages  from  the  employment  of  o})iate  sup- 
positories or  of  opiate  enemata  as  to  induce  me  to  prefer  that  mode 
of  giving  opium  to  its  administration  by  tlie  mouth  ;  and  I  may 
further  add,  that  the  local  employment  of  the  vapor  of  chloroform 
by  means  of  Dr.  Hardy's  very  ingenious  contrivance,  has  hardly 
ever  proved  sufficiently  powerful  to  give  much  relief  to  the  patient. 
Another  local  anaesthetic,  which,  however,  has  disappointed  those 
who,  like  myself,  have  recently  made  trial  of  its  efficacy,  is  fur- 
nished by  directing  a  stream  of  carbonic  acid  gas  against  the  ulcer- 
ated surface.  This  agent  has  been  used  at  various  times  within 
the  past  thirty  years  for  the  purpose  of  allaying  uterine  pain,  but 
the  isolated  instances  of  its  employment  attracted  little  notice  till 
attention  was  recently  directed  to  the  subject  by  Professor  Simp- 


TREATMENT     OF    THE     PAIN.  321 

son,  of  Edinburgh.!  He  speaks  of  its  results  as  uncertain;  since 
in  some  cases  it  completely  failed,  while  in  others  the  success  that 
foHowed  its  use  was  striking  and  immediate;  but  his  [>aper  con- 
tains few  definite  details  with  reference  to  its  employment.  Some 
trials  have  since  been  made  of  it  in  Paris,^  the  action  of  the  remedy 
still  appearing  to  be  uncertain,  and  its  effect  now  and  then  to  be 
that  of  aggravating  instead  of  mitigating  suffering,  while  in  a  few 
instances  headache,  drowsiness,  and  depression  followed  its  em- 
ployment, though  not  to  a  serious  degree,  and  subsiding  spontane- 
ously in  a  few  hours  after  the  discontinuance  of  its  use.  According 
to  M.  Bernard,  who  has  written  most  fully  on  the  subject,  the  un- 
pleasant symptoms  were  less  frequently  produced,  and  in  a  slighter 
degree,  in  cases  of  uterine  carcinoma,  than  in  those  in  which  the 
vapor  was  applied  for  the  mitigation  of  pain  consequent  on  con- 
gestion or  inflammation  of  the  womb.  In  some  instances  the 
continued  emplo3'ment  of  the  gas  for  some  ten  minutes  twice  a 
day  during  several  weeks  was  followed  not  only  by  a  great  miti- 
gation of  suffering,  but  also  by  a  great  improvement  in  the  state 
of  the  womb  itself  and  by  a  partial  cicatrization  of  the  ulcer.  In 
otlier  cases,  however,  the  local  condition  remained  unchanged, 
though  for  a  time  the  health  improved  in  proportion  as  the  pre- 
viously severe  pains  were  lessened. 

'  Nothing  can  be  simpler  than  the  mode  of  applying  the  gas.  In 
a  glass  vessel  capable  of  containing  a  pint,  and  such  as  is  used  for 
the  disengagement  of  gases,  either  carbonate  of  soda  and  tartaric 
acid,  or  chalk  and  sul})huric  or  muriatic  acid,  or  carbonate  of  soda 
and  bisul})hate  of  potass  maybe  placed,  and  water  being  added  in 
quantity  sufficient  to  cover  them,  the  gas  maybe  conducted  through 
an  elastic  tube  into  the  vagina,  while  a  cloth  applied  to  the  external 
parts  \y\\\  prevent  its  too  rapid  escape.  M.  Bernard,  who  uses  25 
grammes  of  bicarbonate  of  soda,  and  20  grammes  of  bisulphate 
of  potass,  or  about  5vi  of  the  former  to  5v  of  the  latter,  estimates 
the  ([uantity  of  gas  disen<raged  from  these  materials  at  about  four 
pints,  which  is  given  out  in  a  period  of  from  ten  to  fifteen  minutes.' 
My  own  experience  of  the  use  of  the  carbonic  acid  gas  in  cases 
of  cancer  is  confined  to  ten  cases,  in  three  of  which  temporary 
relief  followed  its  employment,  while  in  two  the  patienf's  suffer- 
ings seemed  rather  increased  by  it,  and  it  was  therefore  discon- 
tinued. In  the  other  five  instances  the  relief  was  not  striking — 
certainly  was  not  greater  than  a  comparatively  small  dose  of  an 
anodyne  would  procure;  nor  was  the  condition  of  the  patient 
otherwise  more  improved  than  might  be  expected  from  the  (piiet 

1  Ohs/r/rlr  Works,  vol.  ii,  )).  7G0. 

2  See  tlip  |.;ipcr,*  of  -M.  Follin,  in  Arch.  Oen.  de  Medecine,  Nov.,  1850,  p.  008,  and 
M.  IJcrriiinl,  il)icl.,  Nov.,  18")7,  p.  iViO. 

»  One  ca.se  of  death  from  the  iiijcotion  of  carbonic  acid  sra.s  into  the  cavity  of 
the  iiteriLS  is  recorded  by  Scaiizoni  at  p.  131  of  vol.  iii  of  lii.s  lieilriige  zur  Ocburts- 
kiinde  nnd  Gi/nfih-tof/ir,' S\o  ,  AVurzhurfjf,  1858.  The  case,  liowcver,  was  not  one 
of  cancer,  and  the  whole  circumstances  attendant  upon  it,  arc  of  so  cxci'ptional  a 
kind  that  no  inference  can  be  drawn  from  thorn  beyond  the  proof  which  they  af- 
ford of  the  pus.sible  death  (jf  a  person  from  tlie  use  of  tiiis  agent. 

21 


322  TREATMENT    OF    THE    DISCHARGES. 

aud  the  comfort  of  an  hospital,  though  on  tlie  other  hand,  no  in- 
conveniences due  to  the  poisonous  influence  of  the  gas  were  pro- 
duced by  its  employment. 

The  idea  of  employing  the  inhalation  of  chloroform  to  relieve 
the  violent  paroxysms  of  uterine  pain,  naturally  suggests  itself  to 
our  minds.  It  is  not,  however,  of  as  much  service  practically  as 
might  have  been  anticipated.  Sometimes  the  pain  is  of  such  in- 
tensity that  chloroform  scarcely  mitigates  it;  not  infrequently 
sickness  and  vomiting  come  on  before  the  patient  is  fully  under 
its  influence;  while  in  a  large  number  of  cases  so  much  depres- 
sion follows  its  use,  and  such  long-continued  irritability  of  the 
stomach,  that  the  patient  herself  is  unwilling  to  purchase  at  so 
dear  a  rate  a  very  short,  and  sometimes  very  imperfect,  immunity 
from  sutt'ering.  Still  it  is  one  of  the  means  which  we  may  try, 
and  in  some  few  cases  it  is  well  borne,  and  gives  much  temporary 
relief. 

The  discharges  which  occur  in  the  course  of  uterine  cancer  call 
for  medical  interference,  either  to  restrain  their  excess,  or  to  cor- 
rect the  ofl'ensive  odor  that  attends  them.  In  the  absence  of  these 
indications,  no  interference  is  desirable  beyond  such  as  mere  atten- 
tion to  cleanliness  ilictates,  and  for  which  tepid  water  is  preferable 
to  any  kind  of  medicated  injection.  Direct  astringents,  such  as 
the  matico  or  tannin,  or  the  decoction  of  oak  bark,  are  useful  in* 
restraining  the  profuse  serous  discharges  which  occur  in  some  cases 
of  epithelial  cancer,  and  are,  I  think,  generally  preferable  for  this 
purpose  to  lotions  of  lead,  or  zinc,  or  alum,  which  more  frequently 
produce  pain,  while  the}-  are  of  less  eflicacy  in  checking  the  super- 
abundant secretion.  Sometimes  the  discharge,  though  of  a  mucous 
or  mucopurulent  character,  is  extremely  profuse,  and  this  is  often 
diminished,  and  the  condition  of  the  ulcerated  surface  secreting  it 
is  improved  by  a  very  weak  acid  lotion,  such  as  5j  of  dilute  nitric 
acid  to  Oj  of  water;  while  more  decided  astringents  will  either  fail 
altogether  of  the  intended  eflect,  or  will  produce  an  increase  of 
pain.  Sometimes,  however,  an  abundant  secretion  from  an  irritable 
ulcerated  surface  is  checked,  and  the  sensibility  of  the  part  dimin- 
ished, by  the  use  of  an  injection  of  5j  of  sulphate  of  iron  and  oiij 
of  extract  of  conium  to  a  pint  of  water.  Now  and  then  the  extreme 
sensitiveness  of  the  ulcerated  surface  is  diminished  by  a  lotion  of 
5ss  of  opium  to  a  pint  of  lead- wash,  but  as  a  general  rule,  the  local 
ap[»lication  of  anodynes  to  the  diseased  surface  is  by  no  means 
eflicacious  ;  and  much  more  relief  is  afforded  by  agents  of  greater 
power,  aud  which  tend  directly  to  alter  the  state  of  the  part.  In 
this  way  great  relief  is  sometimes  given  by  strong  solutions  of 
caustic,  which,  at  the  same  time,  are  a  most  powerful  means  of 
destroying  the  horribly  offensive  odor  that  attends  upon  the 
sloughing  and  detachment  of  portions  of  cancerous  outgrowth.' 
A  solution  of  9j  to  oss  of  nitrate  of  silver  in  5j  of  water  injected 
immediately  into  the  diseased  tissue,  has  the  effect  both  of  destroy- 
ing the  bad  odor,  and  also  of  hastening  the  separation  of  the  slough. 
The  employment  of  this  daily  for  one  or  two  days  generally  suffices, 


TREATMENT  OF  CANCEROUS  CACHEXIA.       323 

but  at  the  same  time  a  weak  solution  of  chloride  of  lime,  such  as 
would  be  formed  by  5ij  of  the  solution  to  Oj  of  water,  or  the  same 
quantity  of  Condy's  liuid,  may  be  used  several  times  a  day  with 
the  etfect  both  of  diminishing  the  fa'tor,  and  of  improving  the 
condition  of  the  ulcerated  surface.  In  far-advanced  carcinoma 
these  remedies  may  cease  either  to  be  useful  or  to  be  admissible, 
but  then  the  crcasote  lotion,  made  with  5j  of  creasote  to  Oj  of 
some  mucihiginous  iiuid,  will  have  a  remarkai)le  influence  in  re- 
moving the  offensive  smell  which  adds  so  much  to  the  distress  of 
the  patient  and  of  those  about  her.  When  the  bladder  or  rectum 
has  been  injured  by  the  advance  of  the  disease,  we  are  unfortun- 
ately reduced  to  mere  ablution,  and  the  use  of  lotions  of  tejjid 
water.  When  this  accident  docs  not  happen,  it  fortunately  occurs, 
as  has  already  been  mentioned,  that  the  disease  of  the  womb  often 
remains  stationary  for  months  together,  and  that  the  patient  is 
spared  at  the  close  of  life  many  of  the  painful  local  symptoms 
which  distressed  her  during  the  earlier  period  of  her  disease. 

And  this  brings  me,  last  of  all,  to  consider  the  management  of 
the  cdiicerouH  cachexia  ;  of  those  symptoms  of  general  constitutional 
disorder,  which,  s[)ringing  from  an  irremediable  cause,  are  sure  at 
length  to  baffle  our  skill.  Most,  and  the  most  distressing,  of  the 
patient's  symptoms,  are  referrible  to  the  state  of  her  digestive 
functions.  She  not  only  loses  strength  with  the  loss  of  blood,  but 
digestion  itself  becomes  generally  im}»aired.  In  some  cases,  indeed, 
as'in  those  of  epithelial  cancer,  in  which  the  most  prominent  symp- 
toms are  those  of  mere  anemia,  iron  is  often  well  borne,  and  is 
then  of  much  service.  I  usually  employ  the  ammonio-citrate  of 
iron  in  five-grain  doses,  three  times  a  day,  giving  it  in  some  effer- 
vescing medicine,  such  as  the  citrate  of  ammonia.  The  stronger 
chalylH,'ate  jtreparations,  or  large  doses  of  the  milder,  often  disagree, 
pro(Uicing  headache  and  feverishncss.  The  failing  appetite  is  some- 
times for  a  time  restored  l)y  the  preparations  of  bark;  but  rather 
by  the  infusion  or  by  small  doses  of  the  liquor  cinchonse  in  com- 
bination with  acids,  than  by  quinine,  which  in  many  instances  is 
not  borne.  A  combination  that  often  suits  is  the  nitro-muriatic 
acid  in  the  infusion  of  cloves  or  of  orange-peel ;  while  throughout 
the  whole  treatment  of  the  disease,  our  remedies  must  be  not  only 
gentle  in  kind,  but  must  be  given  in  small  doses. 

In  most  cases  the  stomach  after  a  time  grows  irritable,  and  the 
tongue  becomes  raw  and  red,  and  aphthous.  The  irritalnlity  of 
the'stomach  is  relieved  by  all  food  and  drink  being  taken  cold,  l)y 
sucking  small  morselsof  ice,  by  very  small  quantities  of  effervescing 
drinks,  or  of  effervescing  wines,  such  as  Cham|»agne  or  the  si);irk- 
ling  Moselle.  Sometimes,  too,  a  mustard  ]»oultice  or  a  slight 
vesication  over  the  epigastrium  will  give  relief,  or  even  the  apjili- 
cation  of  a  piece  of  lint  soaked  in  the  acetum  opii.  The  hydro- 
cyanic acid  may  be  tried,  and  sometimes  it  gives  relief,  but  its 
benefits  are  usnally  more  marked  when  combined  with  ether  than 
when  given  alone.  The  sense  of  sickness  and  liiintness,  unaccom- 
panied by  actual   vomiting,  which  olten  becomes  very  distressing 


324       TREATMENT  OF  CANCEROUS  CACHEXIA. 

as  the  disease  advances,  is  in  many  instances  relieved  by  sal  vola- 
tile, in  doses  of  forty  to  sixty  drops,  or  by  the  compound  tincture 
of  ammonia.^ 

The  soreness  of  the  mouth,  however,  sometimes  precludes  the 
administration  of  stimulants,  and  even  renders  the  taking  food  a 
source  of  extreme  suftering-.  This  state  is  often  much  relieved  by 
the  chloi-ate  of  potash,  of  which  a  quarter  to  half  an  ounce  may  be 
taken  in  the  course  of  the  day,  in  a  pint  of  barley-water  flavored 
with  a  little  orange  or  lemon  peel;  but  the  unpleasant  soapy  taste 
which  it  leaves  behind  often  disgusts  the  patient,  and  compels  us 
to  discontinue  its  use.  In  some  of  these  cases  the  soreness  of  the 
mouth  and  the  dry  burning  sensation  in  the  throat  are  relieved  by 
a  spermaceti  draught,^  which  also  furnishes  a  convenient  vehicle 
for  opiate  preparations  in  cases  where  diarrhoea  is  present.  The 
diarrhcBa  is  usually  a  temporary  symptom  only,  and  yields  for  the 
most  part  to  aroniatics  and  opiates  tolerably  readily,  though  when 
it  occurs  at  a  very  advanced  stage  of  the  disease,  and  when  the  vi- 
tal powers  are  much  weakened,  it  sometimes  carries  otFthe  patient. 
The  disposition  to  constipation  is  a  much  more  frequent  source  of 
distress ;  and  it  is  of  great  moment  not  to  allow  tlie  bowels  to 
remain  many  days  without  being  acted  on.  From  neglect  of  this 
precaution,  1  once  knew  constipation  to  continue  for  eighteen  days, 
when  the  patient  died  with  an  enormously  distended  abdomen,  and 
ill-marked  symptoms  of  peritonitis.  There  was  no  mechanical 
obstacle  to  the  passage  of  the  fiTeces,  but  they  had  been  allowed  to 
accumulate  till  the  feeble  muscular  power  of  the  intestines  was 
insuthcient  to  propel  their  contents ;  n)edicine  irritated  the  stomach, 
and  caused  vomiting,  without  producing  any  action  of^the  bowels, 
and  peritoneal  inflammation  at  length  came  on,  just  as  it  does  in 
a  case  of  strangulation  of  the  intestines. 

I  know  no  other  ordinary  incident  in  the  course  of  uterine  cancer 
which  calls  for  special  notice  now ;  but  I  would  have  you  bear  in 
mind  that  when  there  has  long  been  no  hope  of  cure,  it  is  yet 
often  within  our  power  to  minister  very  largely  indeed  to  the  com- 
fort of  the  patient,  to  soothe  distress,  and  mitigate  suftering  which 
otherwise  would  be  utterly  intolerable. 

Reference  was  made  in  the  last  Lecture  to  the  dangers  which 
attend  on  pregnancy  and  labor  when  associated  tvith  cancerous 
disease  of  the  neck  of  the  ivomb.  In  not  a  few  instances  of  this 
complication,  abortion  or  premature  labor  occurs,  owing  to  the 
disease  not  allowing  of  those  changes  which  with  advancing  preg- 
nancy ought  to  take  place  in  the  lower  segment  of  the  uterus. 
In  such  circumstances,  greater  suftering,  and  more  considerable 
hemorrhage  than  ordinary,  usually  attend  the  miscarriage.    I  have 

1  See  Formula  No.  9,  p.  75. 
2  (No.  11.) 
R.     Cetacei, 

Pulveris  Tragacanthre,  aa  .  .  .  5J 
Svrupi  Papaveris  albi,  .  .  .  .'  g;j 
Aquae  destillatas, 3x1.— M.  f.  Haustus. 


MANAGEMENT     OF    LABOR    AVITII    CANCER.  6ZD 

indeed  known  the  lovss  of  blood  to  be  so  considerable  as  to  occasion 
the  patient's  death  in  a  few  days;  while  thouf^h  she' •should  .'sur- 
vive this  danger,  and  the  subsequent  risk  of  peritoneal  inHaninia- 
tion,  the  cancerous  disease  generally  advances  more  rapidly  than 
before.  Still  the  dangers  which  attend  upon  the  miscarriage  are 
not  to  be  put  in  coniiiarison  with  those  that  accompany  labor  at 
or  near  the  full  period  of  pregnancy.  In  some  instances  labor 
pains  have  come  on,  but  the  os'uteri  not  yielding,  the  contractions 
of  the  organ  have  again  subsided,  and  the  patient  has  at  length 
died  painfully,  after  gestation  protracted  for  months  beyond  the  full 
period.  More  cominonly,  either  the  womb  gives  way  during  the 
labor,  or  the  violence  inflicted  on  it  durino;  the  passage  of  the  foetus 
or  its  instrumental  extraction,  proves  immediately  or  speedily 
fatal ;  and  on  this  account  it  is  laid  down  as  a  general  rule,  that 
abortion  or  premature  labor  should  be  induced  in  cases  of  this 
description...  The  rule  is  doubtless  a  sound  one,  though  something 
of  its  applicability  must  depend  on  the  extent  of  the  disease,  and 
the  stage  of  pregnancy  at  the  time  of  the  patient  coming  under 
our  ol)servation.  If  the  mischief  should  appear  to  be  already  so 
far  advanced  as  to  preclude  any  reasonable  expectation  of  life  being 
prolonged  by  medical  or  surgical  treatment,  while  at  the  same  time 
there  does  not  seem  to  be  any  insuperable  obstacle  to  the  passage 
of  the  child,  it  would  be  the  better  plan  to  allow  pregnancy  to  o;o 
on  without  interruption  ;  inasmuch  as  while  the  life  of  the  child 
might  be  thereby  preserved,  the  mother  herself  would  be  more 
likdyto  retain  comparatively  good  health  during  the  remainder  of 
gestation,  and  the  disease  to  make  less  rapid  [irogrcss  than  during 
an.  equal  space  of  time  after  the  womb  had  been  emptied  of  its 
contents.  In  some  instances,  too,  the  disease  is  found  to  be  so 
extensive  as  to  offer  an  apparently  insurmountable  obstacle  to  the 
rupture  of  the  membranes,  or  to  any  other  mode  of  bringing  on 
miscarriage,  and  here  the  great  immediate  peril  of  interference 
must  be  allowed  to  counterbalance  the  remoter  risks  of  delay. 

When  labor  actually  comes  on,  it  is  often  the  case  that  free 
incisions  into  the  os  uteri  and  the  cervical  canal  are  the  only  means 
by  which  such  a  dilatation  of  the  ])assages  can  be  obtained  as  will 
allow  of  the  birth  of  the  child.  8till  \t  is  important  not  to  be 
premature  even  in  these  cases  in  resorting  to  o])erative  interference. 
I  remember,  years  ago,  when  a  student  in  Paris,  a  patient  was 
received  into  the  Clinique  des  Accouchemens  in  an  advanced  stage 
of  pregnancy,  and  suflering  at  the  same  time  from  extensive  can- 
cerous'disease  of  the  womb.  Professor  Dubois  mentioned  her  casQ 
to  the  class,  and  spoke  with  consideral^le  certainty  of  the  necessity 
for  incising  the  neck  of  the  womb  when  laljor  should  come  on. 
Contrary  to  all  expectation,  however,  the  os  uteri  dilated  readily 
to  admit  of  the  passage  of  the  child,  and  the  labor  was  but  of  a 
•'  few  hours'  duration.  That  which  happened  in  this  case,  I  myself 
ol)served  in  another  instance,  where  the  comparatively  small  jtart 
of  the  lower  segment  of  the  womb  which  was  not  implicated  in 


326  RADICAL    CURE    OF    CANCER. 

the  disease  stretched  beyond  what  might  have  been  supposed  pos- 
sible, and  in  spite  of  the  unyielding-  condition  of  the  bulk  of  the 
cervix,  thus  made  room  for  the  passage  of  the  child.  But  so  soon 
as  labor  has  advanced  far  enough  for  us  to  be  really  satisfied  of 
the  necessity  for  interference,  and  to  determine  the  direction  in 
which  incisions  should  be  made,  and  the  extent  to  which  they 
should  be  carried,  any  farther  delay  would  add  to  the  patient's 
changer,  without  any  corresponding  advantage. 

The  question  has  been  raised,  whether  in  cases  where  the  disease 
is  very  extensive,  •  and  the  impediments  to  the  passage  of  the 
child,  or  to  the  employment  of  instruments  for  its  extraction,  very 
great,  it  might  not  be  less  hazardous  to  remove  the  child  by  the 
C?esarean  operation  ?  Dr.  Oldham,'  however,  is,  to  the  best  of  my 
knowledge,  the  only  person  who  has  carried  out  the  idea  in  prac- 
tice ;  and  the  favorable  result  of  his  case,  as  far  as  the  issue  of  the 
labor  was  concerned,  proves  the  wisdom  of  the  choice  which  he 
made.  Desperate,  however,  must  be  the  state  of  a  patient,  when 
of  two  alternatives, the  Csesarean  section  is  the  less  hazardous. 

And  now,  having  considered  the  indications  which,  in  the  great 
majority  of  cases  of  uterine  cancer,  we  may  have  to  fulfil,  and  the 
best  mode  of  accomplishing  them,  we  come,  in  conclusion,  to  the 
examination  of  different  proceedings  that  have  been  recommended 
either  for  the  extirpation  of  the  diseased  organ,  or  for  the  removal 
of  the  diseased  portion  of  it,  or  for  retarding  by  various  local 
measures  the  rapid  progress  of  the  evil. 

First  among  these  proceedings  we  must  consider  the  removal  of 
the  tvhole  uterus,  though  in  spite  of  one  or  two  temporary  successes 
which  have  followed  its  performance,  the  unanimous  voice  of  the 
profession  has  pronounced  it  to  be  overbold,  and  has  rejected  it 
from  among  the  legitimate  operations  of  surgery. 

The  only  instance  with  which  I  am  acquainted  of  permanent 
recovery  after  the  complete  extirpation  of  the  cancerous  uterus,  is 
that  in  which  the  elder  Langenbeek  removed  the  long-[)rocident 
organ  from  a  woman,  who  lived  free  from  disease  for  twenty-six 
years  afterwards.^  In  the  first  place,  however,  it  is  by  no  means 
certain  that  the  induration  and  ulceration  were  due  to  anything 
else  than  the  irritation  of  the  organ  from  long  exposure  to  external 
injury;  and  even  though  it  were,  you  will  yet  remember  that  the 
sensibilities  of  the  womb  become  so  lessened  by  low/  residence 
out  of  the  pelvis,  that  no  inference  can  be  drawn  as  to  the  danger 
of  operations  on  the  organ  when  in  situ  from  the  results  obtained 
when  it  has  been  long  procident.  So  favorable  a  conjuncture  as 
that  met  with  in  Langenbeck's  case,  and  which  no  doubt  much 
facilitated  the  difficult  task  of  shelling  out  the  organ  from  its  peri- 

1  Gxi/'s  Hnapiinl  Reports,  1851,  second  series,  vol.  xi,  p.  426. 

2  The  particulars  of  which  are  detailed,  and  drawings  showing  the  appearances 
after  death  are  given,  together  with  much  important  information  concerning  the 
operation,  by  the  present  Professor  Langenbeek,  in  his  inaugural  dissertation  De 
totius  uteri  exthyatione,  4to.,  Gottingse,  1842. 


OPERATIONS  ON  THE  CANCEROUS  UTERUS, 


327 


toneal  investment,  must  be  of  extreme  rarity,  and  few,  indeed, 
are  the  instances  in  which  it  has  existed.' 

Attempts  have  been  made  artificially  to  produce  a  state  of  pro- 
lapse of  the  womb,  and  thus  to  ajiproximate  the  conditions  of  the 
operation  to  those  which  existed  in  Langenbeck's  case,  but  with 
little  success ;  while  some  have  removed  the  organ  through  the 
vagina  without  any  attempt  at  altering  its  position  ;  and  once  the 
abdominal  cavity  was  laid  open,  and  the  womb  removed  throngh 
the  incision.  I  need  not  enter  into  a  long  critique  of  these  differ- 
ent proceedings,  when  I  have  told  you  that  of  25  cases,  22  ter- 
minated fatally  in  consequence  of  the  operation,  and  that  two 
months,  four  months,  and  a  year,  were  the  respective  periods  dur- 
ing which  the  patient  survived  in  what  are  termed  the  successful 
cases. '■^ 

Of  the  22  fatal  cases,  4  terminated  within  six  hours,  and  4  more 
in  twenty-four  hours,  7  in  two  da^^s,  2  in  three  days,  2  in  four 
days,  1  in  a  few  days,  1  in  ten  days,  and  in  1  the  duration  of  life 
is  not  stated,  though  the  patient  is  said  to  have  died  from  the 
effects  of  the  operation. 

In  21  cases  the  cause  of  death  is  stated,  and  appears  to  have 
been  the  pain  or  shock  of  the  operation  in  8  instances,  hemorrhage 
in  3,  hemorrliage  and  sliock  in  2,  peritonitis  in  6,  peritonitis  and 
shock  in  1,  and  a  so-called  nervous  fever  in  another  instance. 

But  while  facts  such  as  these  ampl}^  justify  the  general  verdict 
of  the  profession,  as  to  the  impropriety  of  attempting  the  complete 


'  A  case  is  on  record  of  the  successful  extirpation  of  the  uterus,  said  to  be  can- 
cerous, by  means  of  the  ligature  and  knife,  performed  in  the  year  1783,  by  M. 
Marschall,  of  Strasburg,  and  reported  in  Salzh.  Med.  Zeitung,  1794,  vol.  i,  p.  136, 
and  another  recently,  by  Bellini,  in  Omodei  Annall  Universalis  for  1828,  vol.  xlyii, 
p.  355.  In  the  latter  case,  however,  the  removal  of  the  uterus  was  only  partial. 
Pah'tta's  case,  in  which  the  patient  died  on  the  third  day,  reported  in  Omodei 
Armnii,  1822,  vol.  xxiv,  p.  43,  cannot  with  propriety  be  included  among  these  cases, 
inasmuch  as  the  removal  of  the  uterus  was  unintentional,  and  the  di-ease  seems  to 
hav(!  been  rather  a  large  fibrous  tumor  dragging  the  uterus  beyond  the  external 
parts,  than  any  form  of  cancerous  aflection.  Kecamier  removed  the  proeident  can- 
cerous uterus  by  ligature  [Arcliives  de  Med.,  vol.  xxx).  The  patient  recovered,  but 
died  of  dysentery  in  three  montlis. 

2  The  subjoined  table  gives,  I  believe,  a  tolerably  accurate  account  of  all  recorded 
cases  of  total  extirpation  of  the  uterus  on  account  of  cancerous  disease  : 

Successful  Cases. 


Operator. 


Recamier,  . 
Sauter,  .     . 

Blundell,    . 


f  Recherches  sur   le  Traitement  du  Cancer,  1829,  \ 

\      vol.  i,  p.  519, J 

r  Die  qdnziiche  Extirpation  d.  Care.  Gebdrmuttei',  \ 

I      1822,    / 

(Lancet,  Oct.  1828.  Med.  Gazette,  vol.  ii,  p.  294,  ^ 
J  and  vol.  iii,  p.  797,  and  M.S.  note  at  com-  I 
1  mencement  of  his  Researches,  &c.,  in  Royal  j 
[     College  of  Surgeons, J 


I'eriod  during 

which  I'utifiiU 

survived. 


2  mimlhs 
4  months 

1  year  all  but  ft 
few  days 


328 


OPERATIONS  ON  THE  CANCEROUS  UTERUS: 


extirpation  of  the  cancerous  womb,  no  such  general  verdict  of  con- 
clenmation  can  be  passed  on  that  less  hazardous  operation  which 
aims  at  the  cure  of  the  disease  in  an  earlier  stage  by  the  removal 
of  the  affected  part.  Xot  to  lose  ourselves  in  fruitless  antiquarian 
investigations,  we  may  date  the  introduction  of  the  amputation  of 
the  cancerous  neck  of  the  womb,  among  the  operations  of  surgery 
from  the  year  1802,  when  it  was  successfully  performed  by  the  late 
Professor  Osiander,  of  Gottingen.  Between  that  time  and  tlie 
year  1816,  Osiander  amputated  the  neck  of  the  womb  in  twenty- 
three  instances,^  and  so  striking  an  innovation  as  this  proceeding 
not  unnaturall}' excited  much  attention  iu  Germany.  The  opera- 
tion did  not,  however,  meet  with  much  encouragement  among 
Osiander's  countrymen,  for  the  sometimes  formidable,  and  in  some 
instances  fatal  hemorrhage  which  often  succeeded  it,  not  unnatur- 
ally deterred  many  from  attempting  it,  while  it  was  further  alleged 

Unsuccessful  Cases. 


Operator. 


Blundell,  . 

u 

Langenbeck, 

u 
Holscher,  . 
Wolff,  .     . 
Siebold,     . 

(1 

Banner, 
Lizars, .     . 
lloux,   .     . 

i( 

Kecaniicr, 
Dubled,     . 

Dieffenbach, 
Dclpoch,    . 
V.  Walthcr, 
Warren,    . 
Bodenstab, 
Fabri,   .     . 


Lancet,  Nov.  22, 1828,  vol.  xv. 


Jr.,    Disserta^ 


Ibid.,  .  .  . 
Ibid.,  .  .  . 
f  Langenbeck, 

1      tion,  p.  52, 

Ibid.,  p.  .55, 

Ibid.,  p.  58, 

J  Graefe  n.  Wali/ier'ii  Jonj-nal, 
\  vol.  vi,  p.  638,  .... 
Ibid.,  vol.  vii,  p.  478,  .  .  . 
(  Journal  f.  Gebtirts/iulfe,  vol. 
1  iv,  p.  507,  ...".. 
Ibid.,  vol.  vii,  p.  GOO, .  .  . 
<i  Lancet,   Oct.    11,    1828,  vol. 

\      XV    p.  '57        

f  Ibid.',    Nov.    29,    1828,' vol. 
\      XV,  p.  269,     ..... 
f  Archives    Gen.   de   Midecine, 
\      Oct.  1829,  p.  238,  .     .     . 

Ibid.,  p.  241, 


Date  of 
Death  after 
Operation. 


"•} 


Journal  Hebdom.,  vol.  vi,  p.  120, 
Ibid.,  vol.  viii,  p.  123, 
f  Operative  Chirurgie,  vol. 

\      p.  800, 

J  Boivin  et  Dug^s  Maladies  de 
\  V  Uterus,  vol.  ii,  p.  35,  .  / 
f  Kilian's  Oj^rationslehre,  Sec,  'X 
\  vol.  iii,  2d  ed.,  p.  261,  note,  j 
J  Am.  Journal  of  Med.  Scie?tces,  \ 
\  1829,  vol.  i"v,  p.  536,  .  .  f 
(  Neue  Zeitschrift  f.  Gehurts-  \ 
\  kunde,  vol.  xviii,  p.  232,  | 
j  Froriep's  Noiizen,  vol.  xii,  "I 
\     No.  20,  p.  319,  .     .     .     .    / 


2J  hours 

9       " 
39      " 

24      " 

2  days 
10      " 

24  hours 
2  days 

65  hours 
2  days 
4      " 

32  hours 

33  " 

24      " 

2  days 
22  hours 

4  days 

3  " 
Immediate 

3d  day 
Immediate 


Alleged  Cause  of 
Death. 


Shock 


Peritonitis 

u 

Nervous  Fever 

Shock 

Peritonitis 


f  Hemorrhage 
\         and  Sliock 

Shock 

J  Hemorrhage, 
t      Pain,  Shock 
Hemorrhage 

u 

f  Shock,      Peri- 
ls     tonitis 

Pain,  Shock 


Hemorrhage 
Shock 


Not  stated 


1  So  stated  in  Langenbeck,  op.  cit,  p.  26,  note  5,  from  sources  there  indicated. 


MODE     OF     OPERATING.  329 

that  even  in  its  originator's  hands  the  operation  failed  more  I're- 
quentl}'  than  it  proved  successful.  There  were  also  personal  de- 
fects of  character  which  always  stimulated  into  activity  numerous 
hostile  critics  of  Osiander's  doings  and  sa^'ings  ;  and  hence,  until 
quite  recentl}',  the  cases  were  very  few  indeed  in  which  the  ampu- 
tation of  the  neck  of  the  womb  was  had  recourse  to  in  Germany. 
In  France,  however,  where  no  such  causes  were  in  action,  the 
operation  met  with  numerous  advocates,  and  it  received  tlie  sanc- 
tion of  Dupuytren,  who  performed  it  on  several  occasions.  The 
remarkable  results  obtained  by  M.  Lisfranc,  who  alleged  that  he 
had  performed  the  operation  ninety-nine  times,  and  in  eighty- 
four  instances  with  lasting  success,  obtained  for  a  time  great  noto- 
riety, both  for  the  proceeding  itself,  and  for  the  surgeon  who  liad 
constituted  himself  its  most  clamorous  champion.  Before  long, 
however,  doubts  but  too  well  founded  were  thrown  on  the  accuracy 
of  Lisfranc's  statements,  and  his  former  pupil,  M.  Pauly,  published 
a  book  in  which  he  asserted,  and  his  assertions  liave  never  been 
disproved,^  that  M.  Lisfranc  overstated  the  number  of  the  opera- 
tions he  had  performed,  and  falsified  their  results  ;  and  further, 
that  in  many  of  the  cases  in  which  he  had  removed  the  cervix,  the 
disease  was  not  cancer  at  all,  but  mere  induration  of  the  neck  of 
the  womb. 

Though  not  altogether  abandoned,  yet  both  in  France  and  in 
this  country,  whereit  had  been  occasionally  performed,  this  op- 
eration fell  into  comparative  disuse,  till  it  was  recently  revived 
with  better  knowledge  of  the  subject,  and  a  juster  ap[)reciation 
both  of  the  cases  which  are  suited  for  it,  and  of  those  for  which 
it  is  not  fitted. 

There  can  be  no  doubt  but  that  formerly  in  mai^y  instances  iu 
which  the  neck  of  the  womb  was  amputated,  no  cancerous  disease 
existed,  and  I  have  myself  seen  the  cervix  uteri  excised,  and  the 
patient  exposed  to  the  present  risk  of  hemorrhage  and  to  the  sub- 
sequent dangers  of  uterine  inflammation,  for  the  removal  of  mere 
induration  of  the  organ.  On  the  other  hand,  the  excision  of  the 
neck  of  the  womb  was  not  infrequently  had  recourse  to  in  cases  ot 
fungoid  carcinoma  of  the' organ  ;  a  form  of  disease  which,  begin- 
ning in  the  substance  of  the  part,  has  already  made  extensive 
progress  when  it  reaches  to  the  surface,  and  does  not  in  general 
give  rise  to  any  obvious  symptoms  of  its  presence,  till  it  has  ad- 
vanced so  far  that  any  attempt  at  its  extirpation  must  be  worse 
than  useless. 

Such  were  the  two  opposite  errors  by  which  this  operation  was 
brought  into  discredit;  by  the  one  it  was  performed  when  need- 
less, by  the  other  when  useless.  I  have,  however,  described  a 
variety  of  malignant  disease  to  which  it  is  applicable,  and  in  which 

1  Those  who  wish  topursuo  the  particuhirs  of  this  riiiarrpl,  not  cri'ditiibloto  rilher 
party,  but  least  so  to  Lisfranc,  will  tind  the  materials  in  Pavily,  Mulmrirs  ife  V  Vtrnis, 
8vo.,  Paris,  18:36,  pp.  427-481  ;  and  Lisfranc,  Clinique  C/ilrin\qicnle,  8vo.,  Paris, 
1843,  vol.  iii,  pp.  038-657.  Lisfranc's  feeble  defence  amounts  almost  to  a  plea  of 
guilty  on  his  part. 


330  .  MODE    OF    AMPUTATING 

its  performance  has  been  found  to  be  most  salutary.  Cases  have 
long  been  on  record  in  which  the  removal  of  cauliflower  excres- 
cence of  the  uterus  has  been  followed  by  the  patient's  complete 
recovery;  and  there  are  other  forms  of  disease  of  more  solid  tex- 
ture, and  endowed  with  smaller  vascularity,  which  present  the 
same  character  of  beginning  on  the  surface  of  the  os  uteri,  and 
only  by  degrees  extending  to  deeper  tissues.  Now  precisely  these 
epithelial  cancers  of  the  uterus  are  they  which  have  been  cured 
by  the  removal  of  the  affected  part,  and  to  such  cases  I  believe  the 
operation  ought  to  be  almost  exclusivelj'  limited.  It  is  to  be  feared, 
however,  that  the  conditions  which  even  in  this  form  of  the  dis- 
ease warrant  the  performance  of  the  operation,  are  comparatively 
seldom  to  be  met  with,  for  though  I  have  been  constantly  looking 
out  for  casers  suitable  for  it,  two  instances  only  have  come  under 
my  observation  in  which  there  could  be  no  hesitation  as  to  the 
propriety  of  the  proceeding.  One  of  the  patients  was  operated 
on  by  Mr.  Arnott,  in  the  Middlesex  Hospital.  There  existed  in 
her  case  perfect  mobility  of  the  uterus,  so  that  but  little  difficulty 
was  ex})erienced  in  drawing  the  organ  down  beyond  the  external 
parts;  while  the  neck  of  the  womb  was  of  snfiicient  length,  and 
seemed  sufhciently  unaltered  at  its  upper  part,  to  warrant  the  ex- 
pectation that  the  excision  might  be  carried  through  healthy  tis- 
sues, and  that  the  disease  might  be  completely  eradicated.  The 
hemorrliage  in  this  case  was  very  formidable,  a  large  arterial  trunk 
pouring  out  blood  in  great  abundance,  and  this  was  restrained 
only  by  the  employment  of  the  actual  cautery,  while  on  the  sep- 
aration of  the  slou<j:h  a  second  outburst  of  hemorrhaice  rendered 
it  necessary  to  plug  the  vagina.  These  dangers  surmounted,  the 
patient's  subsequent  recovery  was  very  rapid  ;  she  regained  flesh 
and  strength,  and  for  nearly  six  months  continued  in  the  enjoy- 
ment of  perfect  health.  Symptoms  of  her  disease  then  reap- 
peared, and  she  died  in  the  course  of  two  months,  eiglit  months 
after  the  performance  of  the  operation.  Even  six  months  of  life, 
of  hope,  of  freedom  from  pain,  of  health  and  happiness,  cannot 
be  thought  dearly  purchased  by  an  operation  which,^even  without 
the  aid  of  chloroform,  is  by  no  means  very  painful,  and  whose 
one  great  danger,  that  of  hemorrhage,  can  generally  be  controlled, 
if  not  averted,  by  the  use  of  the  plug.  The  other  case  was  still 
more  satisfactory,  for  life  was  prolonged  for  more  than  a  year,  and 
death  then  took  place  from  an  accidental  attack  of  bronchitis 
without  any  symptom  of  the  recurrence  of  her  disease  having 
manifested  itself,  while  the  use  of  the  ecraseur  entirely  prevented 
the  hemorrhage  which  in  the  other  instance  had  been  so  for- 
midable. 

The  operation  has  been  performed  in  various  w^ays ;  either  by 
drawing  the  uterus  down  with  hooks  so  as  to  bring  the  diseased 
part  beyond  the  vulva,  just  as  in  the  excision  of  polypi;  or,  with- 
out displacing  the  organ,  by  simply  cutting  through  the  cervix, 
either  with  or  without  the  previous  introduction  of  the  speculum, 
with  a  curved  bistoury,  a  pair  of  scissors,  or  an  instrument  specially 


THE    CERVIX     UTERI.  331 

contrived  for  the  purpose,  of  which  the  most  ingenious  is  Colom- 
bat's  hysterotome.'  It  is  very  doubtful,  indeed,  whether  any 
specuhnn  could  embrace  the  really  cancerous  cervix,  and  yet  leave 
room  for  the  dexterous  manipulation  of  a  bistoury  or  a  pair  of 
scissors.  All  complex  instruments,  such  as  Coloml)at's,  are  found 
in  practice  to  be  open  to  objections  which  tlieir  inventor  never 
anticipated,  and  in  spite  of  the  obvious  advantages  of  meddling 
no  more  than  is  absolutely  necessary,  I  should  prefer,  whenever 
it  is  not  attended  by  much  difHculty,  and  can  be  accomplished 
without  violence,  to  draw^  down  the  uterus  before  dividing  the 
cervix.^  This  is  to  be  done  by  means  of  hooked  forceps  inserted  • 
into  the  neck  of  the  womb,  just  as  they  are  inserted  into  a  poly])US 
which  we  are  about  to  extirpate,  and  the  parts  maybe  divided  by 
strong  probe-pointed  scissors,  curved  in  the  direction  of  their 
shank,  not  in  that  of  their  cutting  edge,  as  is  the  case  with  Osian- 
der's  scissors,  which  have  been  much  used  for  this  purpose.  The 
position  in  which  the  patient  is  placed  is  that  usually  adopted  for 
lithotomy;  but  Dr.  Simpson'' recommends  that  she  be  placed  on 
her  face,  with  the  legs  hanging  over  the  edge  of  the  couch,  as  in 
operations  for  hemorrhoids.  The  reason  which  he  assigns  for  it 
is  a  weighty  one,  and  is  probably  the  same  as  induced  Lisfranc  to 
cut  from  behind  forwards^ — namely,  that  as  the  peritoneum  de- 
scends much  further  behind  the  neck  of  the  womb  than  in  front 
of  it,  there  is  much  more  risk  of  wounding  it  in  an  incision  carried 
from  before  backwards,  than  if  it  were  made  in  the  opposite 
direction.  I  should  imagine,  however,  that  if  this  danger  is 
borne  in  mind,  it  will  not  be  difficult  to  avoid  it  without  i)lacing 
the  patient  in  this  very  constrained  attitude,  wdiich,  among  other 
inconveniences,  has  that  of  preventing  the  safe  administration  of 
chloroform. 

Though  the  hemorrhage  after  the  operation  is  sometimes  very 
formidable,  and  has  been  known  indeed  in  several  instances  to 
prove  fatal,  I  am  yet  disposed  to  think  that  the  actual  risk  to  life 
from  loss  of  blood  has  been  overestimated,  and  that  the  danger  of 
the  supervention  of  phlebitis  or  inflammation  of  the  peritoneum  is 
in  reality  the  more  serious.  Something  of  the  risk  of  bleeding, 
too,  may  be  referred  to  the  inetHcient  way  in  which  the  sim}>le 
operation  of  plugging  the  vagina  is  not  infrequently  performed. 

1  For  a  description  and  drawini;;  of  this  instrument,  soc  INIfisrs's  translation  of 
Colombiit's  work  on  Diseases  <>/  Women,  8vo.,  Pliiladcdphia,  1845,  p.  351. 

'•^  In  drai^i^incj  down  the  uterus,  however,  much  caution  must  be  observed ;  since, 
as  Scanzoni  mentions,  op.  cii.,  p.  2G4,  it  is  by  no  means  unusual  for  adhesions,  the 
result  of  peritonitis,  to  form  between  the  uterus  and  adjacent  parts,  even  in  tlie 
early  stages  of  canc(*rous  disease  of  the  womb.  If  these  adiiesions  were  torn  or 
violently  stretched,  fresh  inflammation  of  an  acute  kind  would  not  fail  to  be  .^et  up ; 
and  Si'aiizoni  even  relates  an  instance  in  which  a  rent  in  the  perit<>nrum  behind 
the  uterus,  two  inches  in  length,  was  produced  during  llie  erturts  to  draw  down  the 
womb  in  order  to  remove  its  cancerous  cervix. 

'  Ohs/efric  Memoirs,  p.  180. 

*  Pauly,  op.  cit.,  p.  473,  asserts  that  hemorrhage  proved  fatal  within  twenty-four 
hours  to  three  out  of  nine  cases  in  which  he  assisted  >[.  Lisfranc.  Such  a  result, 
however,  is  quite  out  of  proportion  to  the  general  e.xjierience  in  this  matter. 


332  AMPUTATION    OF    THE     CERVIX     UTERI. 

Except  during  labor,  it  cannot  be  thoroughly  clone  without  the 
use  of  the  speculum.  The  comparatively  narrow  vulva  and  entrance 
of  the  vagina  render  the  introduction  of  the  tow  or  cotton-wool  a 
very  tedious  process  ;  and  the  lower  part  of  the  canal  is  already 
filled,  while  its  wider  and  extensile  upper  portion  is  so  little  dis- 
tended that  ample  room  is  left  for  the  accumulation  of  a  large 
quantity  of  blood  between  the  uterus  and  the  plug,  until  at  length 
under  some  efibrt  at  vomiting,  or  some  sudden  movement,  an 
enormous  coagulum  and  the  plug  are  expelled  together,  and  the 
bleeding  breaks  out  afresh. 

The  question  is  not,  however,  whether  the  excision  of 'the  neck 
of  the  womb  in  these  cases  is  unattended  by  immediate  risk,  but 
whether  such  risk  is  greater  than  would  attend  any  other  opera- 
tion performed  for  the  same  purpose  ?  That  dread  of  hemorrhage 
which  has  led  some  practitioners  to  prefer  the  ligature  to  the  kniie 
for  the  removal  of  polypi,  has  also  had  much  influence  in  pre- 
venting the  excision  of  the  cervix,  and  has  consequently  led  to 
the  restriction  of  attempts  at  cure  to  those  softer  varieties  of 
epithelial  cancer,  in  the  removal  of  which,  as  of  true  cauliflower 
excrescence,  the  ligature  is  available.  1  employed  the  ligature 
with  advantage,  and  without  the  occurrence  of  any  alarming 
symptom,  not  indeed  for  the  cure  of  the  disease,  but  for  the  re- 
moval of  an  enormous  mass  of  epithelial  cancer,  which,  sprouting 
from  the  cervix  uteri,  occupied  and  distended  the  whole  vaginal 
canal.  In  another  instance,  however,  of  less  extensive  disease,  in 
which  I  saw  tlie  ligature  employed  in  the  hope  of  eftecting  a  cure, 
the  patient  died  of  phleljitis;  and  Dr.  E.  Watson,^  who  has  col- 
lected such  scanty  statistics  as  can  be  brought  to  bear  on  the  sub- 
ject, gives  the  following  result  of  his  inquiries.  Of  seven  patients 
operated  on  by  ligature,  one  died  four  months  after  of  inflamnui- 
tion  of  the  womb,  which  threatened  to  prove  immediately  fatal, 
and  probably  would  have  done  so  but  for  the  removal  of  the 
ligature  on  the  sixth  day  after  its  application.  In  every  one  of 
the  others  the  disease  speedily  reappeared,  but  the  life  of  one  of 
the  number  was  saved  by  the  excision  of  the  remainder  of  the 
cervix,  an  operation  which  was  performed  by  Dr.  Montgomery  of 
Dublin.  Of  nine  patients  in  whom  the  cervix  uteri  was  excised, 
none  died  from  the  immediate  effects  of  the  operation  ;  the  disease 
returned  in  three;  in  five  the  cure  was  permanent;  and  the  con- 
dition of  one  patient  was  doubtful,  since  her  history  was  not 
brought  down  later  than  the  eleventh  day.  Excision  of  the  part 
seems  to  me  the  preferable  proceeding,  because  it  is  applicable  to 
cases  where  the  ligature  cannot  be  employed,  because  the  present 
risk  which  attends  it  is,  to  say  the  least,  not  more  considerable, 
while  the  prospect  of  a  permanent  cure  is  far  greater.  This 
opinion  seems,  too,  to  be  that  of  the  profession  generallj';  for 
while,  as  far  as  I  am  aware,  no  fresh  instance  has  been  recorded 
of  the  employment  of  the  ligature  since  the  publication  of  Dr. 

1  Monthly  Journal,  Nov.  1849,  p.  1183. 


LOCAL    EMPLOYMENT    OF    COLD.  333 

"Watson's  paper,  there  are  many  additional  cases  of  tlie  removal 
of  the  diseased  cervix  by  excision.  " 

Since  the  date  of  Dr.  Watson's  paper,  many  attempts  have  been 
made  to  combine  the  permanent  advantages  of  the  operation  by 
excision  with  the  greater  present  safety  of  the  ligature  by  the  use 
of  the  ecraseur.  It  seemed,  Ijowever,  as  if  this  change  in  the  mode 
of  operating  did  but  substitute  a  new  danger  for  the  old  one,  and 
one  so  grave  as  to  more  than  counterbalance  the  safeguard  whicli 
the  ecraseur  afibrds  against  hemorrhage.  The  instrument  ap[>cars 
so  apt  to  draw  within  its  chain  parts  not  involved  at  the  time  of 
its  first  application,  that  the  peritoneum  has  on  several  occasions 
been  wounded  in  the  attempt  to  amputate  the  neck  of  the  womb. 
This  ol)jcction  was  recently  urged  against  it  at  a  meeting  of  the 
Berlin  Obstetrical  Society,  by  Dr.  Mayer,  who  referred  to  an  in- 
stance in  which  this  accjident  had  occurred  to  a  patient  of  Pro- 
fessor Langenbeck;  and  Dr.  Biefel  on  the  same  occasion  mentioned 
a  case  of  fatal  injury  to  the  bladder  and  peritoneum  by  the  instru- 
ment.^ A  case  of  injury  to  the  vagina,  and  protrusion  of  the 
intestine  through  the  opening,  is  likewise  related  by  Dr.  Breslau,- 
but  his  patient  happily  survived,  as  also  did  another  whose  case 
came  to  my  knowledge,  and  in  whom  a  portion  of  the  peritoneum 
behind  the  uterus  was  removed  with  the  diseased  cervix.  It  has 
been  proposed  by  M.  Simon,  of  Darmstadt,Mn  order  to  avoid  this 
danger,  that  in  all  cases  where  the  uterus  admits  of  being  drawn 
down  beyond  the  external  parts,  a  needle,  or  two  needles,  should 
be  thrust  through  the  neck  of  the  womb,  and  the  ecraseur  should 
be  a[)plied  below  them.  He  rejects  the  ecraseur,  however,  abso- 
lutely in  all  cases  where  the  uterus  cannot  be  drawn  down  ex- 
ternally, though  it  is  doubtful  whether,  even  here,  Dr.  Braxton 
Ilicks's  wire  ecraseur  or  jSIiddledorflfs  application  of  the  red-hot 
galvanic  wire  may  not  stand  us  in  good  stead,  and  avoid  the  risk 
of  hcmorrliage  without  substituting  for  it  a  new  peril. 

The  cases  in  which  any  of  these  proceedings  are  applicable, 
must  obviously  be  comparatively  few  and  exceptional;  since  the 
disease  admits  of  being  extirpated  only  when  comparatively  limited 
in  extent,  and  at  a  comparatively  early  stage  of  its  progress.  Is 
there  then  no  resource  in  these  circumstances  but  to  watch  the 
daily  advance  of  the  evil;  or  can  anything  be  done  to  retard,  if 
not  to  cure,  to  alleviate  the  patient's  suffering  and  to  postjione  for 
some  weeks  or  months  the  inevitable  result?  Dr.  James  Arnott,'* 
to  whose  ingenuity  we  owe  many  very  important  suggestions  in 
medicine  and  surgery,  believes  and  adduces  evidence  to  show  that 
by  the  systematic  application  of  a  very  low  temperature  to  i)arts 
affected  with  cancer,  the  |)ain  of  which  they  are  the  seat  may  be 
greatly  diminished,  the  advance  of  the  disease  may  be  consider- 

'  MonnUrhr.f.  Oeburfsk.,  Miirt-h,  1858,  p.  lr,9. 
'  Sciinzurii's  JJciiriif/e,  vol.  iii,  'NVufzlnirg,  1858,  p.  80. 
"  Monalsriirlft  f.  Gehiirfn/^iDule,  vol.  xiii,  pp.  418-484. 

*  On  the  TreMimeni  nf  Cancer  by  the  regulated  application  of  an  Amxsthetlc  Tem~ 
jteraturc,  8vo.,  London,   1801. 


334  APPLICATION    OF    CAUSTICS 

ably  retarded,  and  ulcerations  of  their  surface  may  even  be  made 
to  assume  a  comparatively  healthy  character.  Practical  difficulties 
in  the  way  of  applying  the  freezing  mixtures  so  often  as  might  be 
desirable,  have  interfered  with  the  trial  of  his  plans  upon  a  large 
scale  in  our  hospitals,  while  some  degree  of  disappointment  has 
been  experiencecl  in  consequence  of  the  proved  inadequacy  of  cold 
to  annul  the  pain  of  surgical  operations  in  other  than  a  very  few 
instances,  and  those  of  the  very  simplest  kind.  ISTotwithstanding 
a  very  kind  letter  of  explanation  which  Dr.  Arnott  was  so  good  as 
to  send  me,  I  have  yet  found  very  great  difficulties  in  the  attempt 
at  employing  freezing  mixtures  in  cases  of  uterine  carcinoma. 
The  necessary  removal  from  bed  to  a  couch,  the  discomfort  of 
the  position,  the  almost  impossibility  of  preventing  the  patient's 
person  from  becoming  wet,  and  the  tenderness  of  the  vagina  and 
external  parts  produced  by  tlie  frequent  introduction  of  a  large 
speculum,  which,  even  when  of  great  size,  seldom  embraces  the 
hypertrophied  cervix  completely,  have  precluded  my  making  such 
a  number  of  trials  of  the  agent  as  would  alone  warrant  me  in 
speaking  with  any  measure  of  confidence  as  to  its  powers. 

Other  agents,  more  potent  and  more  easily  applied,  have  been 
used  in  cases  of  uterine  cancer,  but  with  results  so  indecisive  that 
opinion  is  still  much  divided  with  reference  to  the  propriety  of 
their  employment.  In  coming  to  a  conclusion  with  reference  to 
the  use  of  any  of  these  remedies,  the  object  with  which  in  each 
instance  it  has  been  liad  recourse  to  must  not  be  lost  sight  of  I 
have  already  mentioned,  that  a  strong  solution  of  nitrate  of  silver 
applied  to  a  cancer  of  the  womb,  in  some  stages  of  the  disease, 
both  diminishes  the  excessive  fa;tor  of  the  discharge,  and  also  ex- 
pedites the  separation  of  sloughs  from  its  surface,  aiding  in  this 
manner  the  attempts  at  a  cure,  which,  though  abortive  as  far  as 
permanent  recovery  is  concerned,  are  yet  most  welcome  pauses  in 
the  course  of  the  disease.  For  this  pur[>ose,  I  believe  a  strong 
solution  is  of  greater  service  than  the  solid  nitrate  of  silver,  prob- 
ably because  in  this  form  the  remedy  penetrates  more  thoroughly 
into  the  affected  tissue.  I  have  also  sometimes  employed  the  acid 
nitrate  of  mercury  to  check  those  granulations  which  in  cases  of 
uterine  cancer  not  infrequently  si»rout  from  the  interior  of  the 
cervix,  and  I  think  that  in  both  of  these  wa3'S  the  use  of  caustics  has 
been  advantageous  as  a  palliative,  not  as  a  curative  proceeding. 

There  are  some  forms  of  external  carcinoma,  in  which  the  em- 
ployment of  the  more  powerful  escharotics,  as  the  chloride  of  zinc, 
has  been  of  great  service;  but  I  need  scarcely  remind  you  that  the 
benefit  derived  from  such  agents  has  depended  almost  entirely  on 
the  possibility  of  completely  destro^-ing  the  affected  tissue,  and 
that,  as  a  general  rule,  its  partial  destruction  has  been  followed 
by  a  more  rapid  development  of  the  disease  than  before.  JSTow, 
in  the  case  of  the  uterus,  it  is  obvious  that  the  thorough  applica- 
tion of  any  deliquescent  substance  is  impossible;  that  the  risk  of 
injuring  adjacent  parts  must  lead  to  the  inefficient  employment 
of  the  caustic,  and  consequently  to  the  aggravation  instead  of  the 


AND  THE  CAUTERY  IN  CANCER.  335 

amendment  of  the  disease.  Tliis  circumstance  leaves  us  no  alter- 
native l)ut  to  resort  to  the  actual  cautery  in  any  case  in  wliich  it  is 
intended  to  do  more  tliau  modily  the  state  of  the  surface  of  the 
alfected  parts.  The  idea  of  the  operation  is  much  more  formid- 
able than  its  reality,  for  it  is  not  very  painful  in  itself,  while  it  can 
always  be  performed  under  chloroform;  and  the  only  real  danger 
attending  it,  that  of  injuring  adjacent  tissues  by  the  radiation  of 
the  heat,  can  always  be  etfectually  guarded  against  by  the  use  of 
a  boxwood  speculum. 

I  have  not  myself  used  it,  or  seen  it  used  sufficiently  often  to 
have  formed  a  very  decided  opinion  with  reference  to  the  an)0unt 
of  benefit  wliicli  may  be  anticipated  from  it;  but  I  feel  satisfied 
that  there  is  no  danger  to  be  apprehended  in  its  employment,  and 
that  it  does  not  tend  to  make  matters  w^orse.  Generally  there  is 
a  vei-y  decided,  though  often  very  temporarj'  mitigation  of  the 
patient's  previous  sufferings,  an  improvement  wliich  has  seldom 
outlasted  the  separation  of  the  eschar.  A  diminution  in  the  quan- 
tity and  foetor  of  the  discharge  has  generally  continued  for  a  longer 
time,  but  I  cannot  say  that  as  yet  I  have  been  able  to  attribute  to 
it  any  delay  in  the  progress  of  the  evil,  partly,  perhaps,  from  not 
having  re[)eated  it  sufficiently  often,  and  in  still  greater  measure 
prol)abIy  from  the  disease  being  already-  far  advanced  when  the 
patients  first  came  under  my  care.  I  believe,  however,  that  like 
other  proceedings  intended  to  effect  the  real  cure  of  cancer,  the 
actual  cautery  is  seldom  indicated  except  in  cases  of  the  epithelial 
form  of  carcinoma,  for  in  that  alone  is  the  mischief  at  all  likely 
to  be  confined  wdthin  limits  which  we  can  hope  to  reach  by  any 
local  treatment. 

These  remarks  are,  I  know,  anything  but  detailed  enough  to 
furnish  a  safe  and  sufficient  guide  as  to  when  and  how,  and  how 
often,  this  kind  of  interference  is  likely  to  be  useful,  or  ma}'  even, 
by  good  fortune,  prove  actually  curative.  They  are  merely  sug- 
gestive of  the  direction  which  your  observations  should  take,  and 
in  which  your  efforts  should  be  made.  Your  duty  and  mine  is, 
not  to  sit  down  in  apathetic  indifference,  doing  nothing,  trying 
nothing  for  a  patient's  cure,  because  her  disease  is  one  which 
hitherto  has  proved  almost  invariably  mortal;  but  rather,  patient- 
ly, carefully,  with  much  distrust  of  our  own  powers,  much  watch- 
ful scrutiny  of  our  own  motives,  to  apply  ourselves  to  the  trial  of 
every  means  by  which  suffering  may  be  mitigated  or  life  pi'o- 
longed.  To  this  our  common  humanity  prompts,  our  obligatitjiis 
as  medical  men  compel  us.  It  is  to  misinterpret  both  very  griev- 
ously, if  we  not  merely  content  ourselves  with  doing  nothing, 
but  take  shelter  under  noisy  censure  of  the  conduct,  and  unchar- 
itable construction  of  the  motives,  of  those  who  read  their  duty 
differently. 


336  INFLAMMATION     OF     THE 


LECTURE    XXII. 

DISEASES  OE  PAKTS  CONNECTED   WITH  THE   UTEKUS. 
INFLAMMATION  AND  ITS  RESULTS. 

Inflammation  of  Uterine  Appendages:  of  the  Cellular  Tissue. 

Causes  of  affection  ;  generally  consequent  upon  delivery  or  abortion ;  its  various 
seats,  and  modes  of  termination  ;  affection  of  the  peritoneum  in  its  course, 
general  tendeucj^  to  end  in  suppuration.     Morbid  appearances. 

Relation  of  this  affection  to  inflammation  of  the  ovaries ;  its  analogy  to  other  in- 
flammations of  the  cellular  tissue. 

Symptoms;  mode  of  attack  twofold.  Formation  of  abdominal  tumor  ;  occurrence 
of  suppuration,  but  chronic  character  of  the  abscess;  various  outlets  by  which 
it  discharges  itself.  Diagnosis  of  the  affection.  Characters  of  intra-pelvic 
tumor  ;  its  similarity  to  uterine  haeniatocele.  General  sketch  of  its  symptoms 
and  course. 

There  are  many  phrases  wliich,  though  still  daily  used  in  medi- 
cal writings,  express  not  merely  the  opinions  but  also  the  errors 
of  a  bygone  time.  It  is  tluis  with  the  term  uterine  ajjpendages, 
long  applied  to  parts  connected  with  the  womb,  some  of  which, 
indeed,  are  secondary  to  it  in  importance,  and  subsidiary  to  its 
functions,  but  others  are  physiologically  of  higher  moment  than 
the  uterus  itself,  and  originate  those  acts  to  whose  due  performance 
the  womb  does  but  minister. 

I  have  no  fear,  however,  lest  by  retaining  the  phrase  appendages 
of  the  uterus,  or  by  speaking  to  you  about  their  diseases,  I  should 
be  suspected  of  ignoring  the  othce  of  the  ovaries,  or  of  implying 
that  they  are  of  less  importance  than  the  womb  in  the  sexual  sys- 
tem of  the  woman.  I  shall  be  understood  to  use  the  term  merely 
as  a  convenient  epithet,  expressing  without  waste  of  words  the 
broad  ligaments  of  the  uterus  and  all  the  various  parts  and  struc- 
tures contained  within  or  intimately  connected  with  them;  parts 
whose  physiological  import  just  now  concerns  us  less  than  do  the 
ailments  to  which  they  are  liable. 

When  speaking  of  the  diseases  of  the  uterus  itself,  we  con- 
sidered iirst  those  which  are  the  result  of  inflammation  ;  and  it 
will.  I  think,  be  convenient  still  to  retain  the  same  arrangement, 
and  before  passing  to  other  subjects  to  study  the  inflammatory  af- 
fections of  the  appendages  of  the  womb.  These  admit  of  being 
classed  under  two  heads,  according  as  the  inflammation  attacks 
the  ovaries  themselves,  or  as  it  is  chiefly  limited  to  the  cellular 
tissue  in  the  immediate  neighborhod  of  the  womb.  In  the  latter 
case  the  symptoms  are  of  course  modified  according  to  the  precise 
seat  of  the  mischief,  which,  tliough  most  frequently  involving  the 
cellular  tissue  between  the  folds  of  the  broad  ligaments,  sometimes 
attacks  that  which  intervenes  between  the  womb  and  the  adjacent 
viscera,  or  extends  to  that  lining  the  pelvic  walls,  or  even  to  that 
which  lies  between  the  outer  surface  of  the  peritoneum  and  the 
abdominal  muscles. 


UTERINE    APPENDAGES.  337 

Inflammation  of  the  cellular  tissue  in  the  neighborhood  of  the 
womb  takes  place  as  a  consequence. of  abortion  or  of  delivery  much 
more  frequently  than  from  any  other  cause.  The  e^reat  tendency 
that  it  has,  too,  to  terminate  in  suppuration,  familiarized  practi- 
tioners of  midwifery  from  a  very  early  period  v^'ith  it;  or  at  least 
with  the  abscesses  to  which  it  gives  rise,  though  misconception 
long  prevailed  with  reference  to  their  nature.  They  were  generally 
innigiued  to  he  secondary  deposits,  the  result  of  a  supposed  metas- 
tasis of  the  milk,  or  of  an  outpouring  of  its  elements  when  i»resent 
in  too  great  abundance  in  the  blood.  It  was  imagined,  too,  that 
this  occurrence  sometimes  took  place  in  one  situation,  sometimes 
in  another,  and  the  most  various  sequelse  of  delivery  were  attrib- 
uted to  this  as  their  remote  occasion ;  a  theoretical  error,  which 
as  Puzos'  essay,  "  Sur  les  Depots  Laiteux,"^  abundantly  proves,  did 
not  at  all  interfere  with  the  most  accurate  description  of  some  of 
the  most  important  ailments  of  the  puerperal  state. 

With  advancing  knowledge  the  erroneus  theory  was  discarded, 
but  the  inflammatory  affections  of  the  uterine  appendages  ceased 
to  attract  attention,  or  were  passed  over  as  occasional  complica- 
tions of  puerperal  fever,  until  attention  was  once  more  drawn  to 
them  quite  recently  by  the  essays  of  Doherty,  Churchill,  and 
Lever,  in  this  country,^  and  by  those  of  Grisolle,  Marchal  de 
Calvi,^  and  others,  in  France.  Even  at  the  present  time,  how- 
ever, and  in  spite  of  the  recognition  of  these  ailments  as  attend- 
ants on  the  puerperal  state,  their  occurrence  independent  of  preg- 
nancy and  its  consequences  has  scarcely  been  appreciated  as 
generally  as  it  deserves,  and  it  is  this  circumstance  which  is  my 
chief  reason  for  bringing  the  subject  now  under  your  notice. 

An  attempt  has  been  made  by  some  writers  to  discriminate 
between  inflammation  of  the  uterine  appendages  occurring  after 
delivery,  and  the  same  atiection  when  coming  on  in  other  circum- 
stances. I  do  not  think,  however,  that  this  distinction  is  called 
for  either  by  the  symptoms  of  the  disease,  or  hj  the  treatment 
which  it  requires  in  the  puerperal  state,  though  the  peculiar  con- 
dition of  the  uterus  at  that  time  often  imparts  to  disease  in  its 
vicinity  a  more  acute  character  than  would  be  presented  by  the 
same  ailment  at  another  season. 

The  subjoined  table  shows  very  clearly  the  influence  of  labor 
and  its  consequences  in  giving  rise  to  inflammation  of  the  appen- 
dages of  the  womb,  and  of  the  cellular  tissue  in  their  immediate 
vicinity.  It  shows,  too,  that  almost  invariably,  even  when  labor 
did  not  precede  the  attack,  some  accident  induced  it,  which  acted 
immediately  on  the  womb,  such,  for  instance,  as  miscarriage,  or 
disorder  of  the  catamenia;  while  the  cases  were  only  7  in  o'J,  in 

1  In  his  Traite  rics  Acc(mc/iemr»s,  4to.,  Pari?,  17-jO.     Soo  especially  pp.  nTjO-SCG. 

«  Dxhl'm  Journal,  vol.  xxii,  1843,  p.  191);  Ibid.,  vol.  xxiv,  1844,  p."  1  ;  and  Guy'a 
IIoHp'ilnl  Reports,  Second  Series,  vol.  ii,  1844,  p    1. 

3  Archivrs  Gen.  de  Meilrcinr,  Third  Series,  1830,  vol.  iv,  pp.  34,  137,  293;  and 
Des  Abcis  I'Ideffinoneux  Intra- Pel vicns,  Svo. ,  Paris,  1844. 

22 


338  CAUSES    OF    INFLAMMATION 

wliicli  the  attack  was  not  brouglit  on  by  some  local  ailment  of  tlie 
sexual  system. 

Occurred  after  Delivery  in 32  cases. 

"           "      Abortion, 11  " 

"           "      Disorder  of  Catamenia, .     .     .  7  " 
"           "      Seduction,  and  some  probable 

violence  to  Uterus,     ...  1  " 
"           "      Ulceration  and  Intiammation 

of  Uterus, 1  " 

"           "     No  ailment  of  Uterus,    ...  7  " 

59 

In  10  of  the  32  cases  in  which  the  affection  succeeded  to  de- 
liveiy  the  patients  were  primiparse  ;  or  if  to  my  own  cases  those 
of  Lever,  of  Marchal  de  Calvi,  and  of  McClintock^  be  added,  56 
out  of  112  cases  were  those  of  women  who  had  been  delivered  for 
the  first  time.  The  supposition,  however,  which  this  i'act  might 
seem  to  suggest,  that  protracted  or  difficult  labor  specially  predis- 
poses to  this  ailment,  is  scarcely  borne  out  by  further  inquiry ;  since 
in  21  of  m}'  32  cases,  and  in  7  out  of  8  of  those  recorded  by  Br. 
Lever,  labor  was  in  all  respects  natural.  In  4  of  my  cases  it  was 
protracted,  though  in  none  was  instrumental  interference  neces- 
sary; in  Lever's  case  turning  was  performed  on  account  of  arm- 
presentation  ;  in  1  case  of  mine  extensive  laceration  of  the  peri- 
neum seemed  to  have  been  the  point  of  departure  of  the  whole  of 
the  subsequent  inflammatory  mischief,  and  in  the  remaining  4 
labor  was  attended  by  profuse  hemorrhage,  an  accident  which  also 
complicated  one  of  the  cases  of  tedious  labor.  From  these  data 
all  that  we  can  venture  to  affirm  is  the  preponderance  of  frequency 
with  which  the  accident  occurs  in  primiparae,  and  an  increase  of 
liability  to  its  occurrence  when  labor  is  more  than  usually  pro- 
tracted, or  when  it  is  accompanied  by  hemorrhage.  M.  GrisoUe 
expresses  his  belief  that  the  omission  on  the  part  of  the  mother 
to  suckle  her  infant  is  one  of  the  most  powerful  predisposing 
causes  of  the  disease,  and  this  opinion  is  in  the  highest  degree 
probable  ;  but  in  this  country  it  is  so  universally  the  practice  for 
women,  especially  among  the  poor,  to  suckle  their  children,  that 
none  of  my  observations  bear  at  all  on  that  point. 

The  nature  of  the  influence  of  abortion,  of  disorder  of  the  cata- 
menial  function,  or  of  other  accidents  which  directly  interfere  with 
the  sexual  organs,  is  too  obvious  to  call  for  explanation.  Why 
under  the  influence  of  such  causes  a  woman  should  be  seized  in 
one  case  by  violent  general  peritonitis,  in  another  by  an  ailment 
chronic  in  its  course,  and  seldom  dangerous  to  life,  it  is  perhaps 
impossible  to  explain.  In  so  far,  however,  as  this  disease  is  a  con- 
sequence of  labor,  it  must  be  borne  in  mind  that  it  is  essentially 
different  from  any  of  the  complications  or  sequelce  of  puerperal 
fever.  Puerperal  fever  is  a  disease  of  the  whole  constitution,  asso- 
ciated with  important  changes  in  the  circulating  system,  probably 

1  0/J.  cit.,  p.  3. 


or    UTERINE    APPENDAGES.  339 

with  otlicr  alterations  too,  which  we  have  not  at  present  the  skill 
to  discover;  but  the  local  mischief  which  may  be  found  after 
deatli  was  no  more  its  occasion,  than  are  the  ulcerations  of  Peyer's 
glands  the  occasion  or  the  essence  of  typhoid  fever.  In  puerperal 
fever,  there  may  be  evidence  of  injury  to  the  uterus,  or  to  its  ap- 
pendages, or  to  its  vessels,  or  to  tlie  peritoneum,  but  there  is  this 
and  something  more;  and  this  something  more,  the  divinum  ali- 
quid,  TO  Osuiv  of  Hippocrates,  has  puzzled  our  philosophy,  eluded 
our  research,  and  outwearied  the  speculations  of  the  most  inge- 
nious theorists  who  have  labored  vainly  to  unriddle  its  nature. 

Hence  it  is,  however,  that  these  inflammations  of  the  uterine 
appendages,  or  of  the  adjacent  cellular  tissue,  do  not  usually  come 
before  us  in  cases  where  puerperal  fever  has  threatened  life,  for 
that  disease  either  destroys  the  patient  speedily,  or  with  the  abate- 
ment of  the  general  disturbance  of  the  system,  the  local  evil, 
unless  the  mischief  done  was  irreparable,  abates  too,  and  soon 
disappears  completely.  This  ailment,  on  the  other  hand,  begins 
as  a  local  affection,  its  early  symptoms  are  often  so  slight  that  it  is 
overlooked  for  days  or  Aveeks  togetlier,  the  constitution  s^-mpathiz- 
ing  just  in  proportion  to  its  extent  and  intensity,  and  general 
health  returning  as  the  consequence  of  the  mitigation  or  of  the 
cure  of  the  local  disease. 

There  does  not  seem  to  be  any  rule  that  determines  absolutely 
either  the  part  which  shall  be  the  seat  of  inflammation,  or  the 
course  which  that  inflammation  shall  run,  and  whether  it  shall 
issue  in  suppuration,  or  may  by  good  fortune  terminate  in  resolu- 
tion. The  cellular  tissue  anywhere  in  the  neighborhood  of  the 
womb  may  be  the  seat  of  the  mischief,  though  that  contained 
within  the  folds  of  the  broad  ligament  is  attacked,  as  the  sub- 
joined table  shows,  far  more  often  than  the  same  structure  in  any 
other  situation,  or  38  out  of  59  times.' 

The  tendency  of  recent  investigations,  too,  is  to  show  that  here, 
or  rather  in  the  ovary  and  Fallopian  tube  of  one  or  other  side,  is 
the  almost  invariable  starting-point  of  the  mischief,  be  the  parts 
eventually  involved  in  it  what  they  may.  The  inflammation 
further  seems  to  extend  from  the  appendages  of  the  womb  to  the 
peritoneum  lining  the  pelvis ;  it  often  ties  down  the  a[ipendages 
behind  the  uterus,  or  forms  adhesions  between  them* and  the  in- 
testines, or  mats  together  the  intestines  themselves,  while  matter 
is  sometimes  formed  in  the  irregular  cavities  left  between  adjacent 
suriaces  of  the  peritoneum,  or  of  the  ialse  membranes  which  con- 
nect diflerent  parts  together.  The  importance  of  this  pelvi- 
pe7-itonitis,  as  he  terms  it,  has  been  much  insisted  on  by  M. 
Bernutz,^  who  seeks  in  it  for  the  adequate  explanation  of  all  the 

1  I  must  bo  allowed  to  correct  an  inadvertence  on  the  jiart  of  31.  Arjin,  who, 
op.  cif.,  p.  G80,  note,  states  that  I  sjlcfje  tlie  tissue  between  the  uterus  and  rectum 
to  be  the  most  frequent  seat  of  this  ati'cction.  The  statement  in  the  text  is  word 
for  word  the  same  as  in  the  previous  edition. 

'■'  In  the  Ardilvcn  de  Medccine,  ]\[areh  iind  Ajiril,  1S.")7,  and  afterwards  at  very 
great  length  in  vol.  ii  of  his  and  ]\I.  Guuiiil's  work,  Sitr  Ics  Maladies  dcs  Fcmiiies, 
already  referred  to. 


340 


INFLAMMATION    OF    CELLULAR    TISSUE. 


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SHARE    BORNE     BY    PERITONITIS.  341 

phenomena,  both  local  and  general,  which  have  usually  been  sup- 
posed to  depend  on  inflammation  of  the  cellular  tissue  about  the 
uterus.  He  would  propose  this  solution  not  of  those  cases  only 
in  which  the  parts  at  the  side  of  the  womb  are  the  seat  of  this 
affection,  but  for  those  also  (14  out  of  every  59  cases)  in  which  the 
inflammation  appears  to  be  seated  between  the  uterus  and  rectum, 
for  here,  too,  the  matting  together  of  the  intestines  may  form  a 
tumor  in  the  recto-vaginal  pouch,  which  may  present  the  characters 
supposed  to  belong  to  pelvic  abscess.  When,  however,  he  denies 
the  possibility  of  inflammation  of  the  cellular  tissue  about  the 
uterus,  with  the  exception  of  that  contained  between  the  folds  of 
the  broad  ligament,  he  goes  furtlier  than  I  am  at  present  prepared 
to  follow  him.  In  4  out  of  my  59  cases  tlie  tissue  intervening 
between  the  uterus  and  bladder  was  the  seat  of  inflanmiation, 
which  in  3  of  the  cases  went  on  to  suppuration,  and  the  matter 
so  formed  twice  escaped  spontaneously,  and  once  was  evacuated 
by  means  of  a  trocar  introduced  through  the  anterior  vaginal 
wall.  To  these  cases  it  is  obvious  that  the  explanation  of  M. 
Bernutz  cannot  apply,  nor  do  I  think  it  holds  good  with  reference 
to  many  instances  of  retro-uterine  tumors;  while,  with  reference 
to  the  broad  ligament  itself,  M.  Bernutz  admits  the  possibility 
of  inflammation  and  suppuration  involving  the  tissue  between 
its  folds. 

The  inflammation  is  in  mau}^  instances  not  limited  to  its  orig- 
inal seat,  but  extends,  and  that  not  always  by  direct  continuity 
of  tissue,  to  the  cellular  tissue  lining  the  pelvis,  or  attacks  that 
which  is  interposed  between  the  abdominal  muscles  and  the  peri- 
toneum, constituting  the  external  peritonitis  of  some  writers.  In 
these  cases,  too,  the  mischief  may  recede  from  the  parts  which  it 
originally  attacked,  and  the  gravity  of  the  secondary  aihnent  may 
entirely  obscure  the  perhaps  transitory  aflection  in  which  it 
originated,  a  supposition  that  will  probably  apply  to  not  a  few  of 
the" instances  in  which  affection  of  the  pelvic  cellular  tissue  and 
that  external  to  the  peritoneum  has  seemed  to  be  idiopathic. 

Like  other  inflammations,  so  these  sometimes  pass  away,  and 
leave  no  trace.  Oftener  they  issue  in  the  production  of  per- 
manent swelling  and  induration,  due  either  to  the  results  of  the 
local  peritonitis,  or  to  actual  thickening  of  the  cellular  tissue 
which  has  been  the  seat  of  the  attack ;  or,  lastly,  they  may  end 
in  the  formation  of  pus,  and  probably  in  its  discharge  through  the 
rectum,  vagina,  or  bladder,  or  now  and  then  in  its  escape  into  the 
cavity  of  the  abdomen.  This  termination  by  suppuration  aii}iears 
to  be  very  frequent  in  the  case  of  those  inflammations  which 
succeed  to  delivery  or  abortion.  I  And  it  noted  as  having  hajiiJcncd 
in  23  out  of  43  instances  in  which  the  inflammation  succeeded  to 
delivery  or  abortion  ;  and  the  large  experience  of  Br.  McClintock' 
leads  to  the  same  conclusion,  since  he  met  with  it  in  37  cases  out 
of  70.     My  own  impression,  too,  formed  chiefly  on  bygone  hospital 

»  Oj).  cit,  p.  9. 


342  POST-MORTEM    APPEARANCES    OF 

experience,  is  that  the  same  rule  holds  good  even  in  those  cases 
where  the  disease  occurs  independently  of  puerperal  causes  My 
table  shows  9  instances  out  of  16  as  having  terminated  by  suppura- 
tion, and  in  this  respect  agrees  with  the  statement  of  M.  Grisolle, 
who  found  it  take  place  in  88  cases  out  of  51.  General  experience, 
however,  it  must  be  confessed,  does  not  bear  out  these  statements. 
M.  Aran  demurs  to  their  correctness,^  and  M.  Gallard,^  in  a  very 
carefully  written  essay,  regards  the  occurrence  out  of  the  puerperal 
state  as  so  rare  as  to  have  been  met  with  only  in  4  out  of  53  cases. 
I  have  no  longer  the  opportunities  of  large  hospital  observation  by 
which  to  control  and  correct  my  own  impressions ;  but  it  seems  to 
me  probable  that  the  cases  which  came  under  my  notice  in  a 
small  Avard  for  admission  into  which  there  were  many  applicants 
at  St.  Tjartholomew's  Hospital,  were  of  a  severer  kind  than  those 
which  formed  the  basis  of  M.  Gallard's  thesis ;  and  further,  that 
many  of  the  slighter  forms  of  what  M.  Bcrnutz  terms  pehi-peri- 
tonitis  may  have  been  taken  into  account  by  observers  recently, 
though  they  would  not  have  entered  into  their  calculations  some 
few  years  ago 

While  I  indicate,  then,  as  I  have  already  done  with  reference  to 
other  questions  bearing  on  this  subject,  the  differences  of  opinion 
which  prevail,  I  am  not  at  present  in  a  position  to  modify  my 
original  statement,  that  the  occurrence  of  suppuration,  or,  at  least, 
of  oedema,  with  infiltration  of  sero-purulent  fluid,  is  in  all  these 
cases  the  rule  rather  than  the  exception,  and  this  even  though  no 
discharge  of  matter  should  at  any  time  take  place  externally. 
The  extreme  rapidity  with  which  a  tumor  forms  so  as  to  be  de- 
tected through  the  abdominal  walls,  or  to  be  felt  in  other  cases 
in  the  vagina,  is  explicable  only  by  the  sudden  pouring  out  of  fluid 
into  the  loose  cellular  tissue;  while  its  varying  extent,  its  ill- 
defined  edges,  its  occasional  disappearance  from  one  side  and 
reappearance  on  the  opposite,  all  serve  to  show  that,  whatever 
may  have  been  its  starting-point,  the  mischief  does  not  in  general 
seriously  involve  the  substance  of  any  solid  organ  such  as  the 
ovary,  and  consequently  to  explain  the  completeness  of  the  patient's 
recovery,  and  the  subsequent  integrity  of  all  her  sexual  functions, 
even  when  the  attack  has  been  most  severe  and  the  symptoms 
have  appeared  most  formidable. 

The  original  seat  of  the  mischief  in  the  cellular  tissue  imme- 
diately adjacent  to  the  uterus  is  illustrated  by  the  subjoined  case, 
where  I  had  the  opportunity  of  observing  after  death  the  process 
by  which  nature  had  eft'ected  the  cure  of  an  inflammation  of  the 
cellular  tissue  contained  Avithin  the  folds  of  the  left  broad  liga- 
ment. The  person  on  whom  this  observation  was  made  was  a 
3^oung  woman  who  died  of  abscess  of  the  liver  fourteen  months  after 
her  recovery  from  inflammation  of  the  uterine  appendages  of  the 
left  side.  The  results  of  examination  when  she  was  originally 
admitted  into  the  hospital,  six  weeks  after  her  delivery,  were  as 

1  Oj}.  cit.,  p.  707.  *  Du  PJdegmon  Peri-uUrin,  4to.,  Paris,  1855. 


INFLAMMATION     OF    CELLULAK    TISSUE.  343 

follows :  the  abdomen  generally  was  soft  and  painless,  but  imme- 
diately over  the  symphysis,  extending  about  two  inches  above  its 
level,  and  about  the  same  distance  transversely,  was  a  firm,  globular 
enlargement,  very  slightly  movable,  tender  on  firm  pressure.  The 
vagina  was  hot,  its  anterior  wall  from  about  half  an  inch  from  the 
orifice  of  the  urethra  was  swollen  into  a  distinct  elastic  tumor, 
which  gave  the  sensation  of  containing  fluid,  and  projected  so  as 
to  contract  to  half  its  ordinary  dimensions  the  calibre  of  the  canal. 
In  this  tumor,  which  was  not  modified  by  the  introduction  of  the 
catheter,  the  anterior  lip  of  the  uterus  was  lost,  while  the  posterior 
lip  was  small  and  natural.  The  right  side  of  the  uterus  was  free 
from  any  unnatural  condition,  the  swelling  existing  to  the  left  and 
anteriorly.  The  uterus  and  tumor,  when  pressed  on,  moved 
together,  but  their  mol)ility  was  very  small.  In  a  few  days  the 
tuinor  felt  per  vagi  nam  was  greatly  lessened  after  a  profuse 
discharge  of  pus,  and  when  the  patient,  after  six  weeks'  sojourn, 
left  the  hospital,  there  was  said  to  be  no  other  morbid  condition 
than  a  thickening  at  the  left  side  of  the  uterus,  by  which  it  was 
almost  completely  fixed  in  the  pelvis. 

The  appearances  found  after  death  explained  this  thickening, 
and  accounted  for  the  non-mobility  of  the  womb,  for  the  folds  of 
the  broad  ligament,  from  the  upper  part  of  the  vagina  to  the  lower 
surface  of  the  ligamentum  ovarii,  inclosed  a  mass  of  dense  cellular 
tissue  of  almost  cartilaginous  liardness,  crying  under  the  knife; 
dense  white  bands  intersecting  each  other  in  all  directions,  and 
having  a  firm,  yellow  fat  between  them.  Tliis  mass  was  closely 
adherent  along  the  whole  leftside  of  the  uterus,  though  the  uterine 
tissue  was  in  no  respect  implicated  in  it.  The  left  Fallopian  tube 
was  tied  at  two  or  three  points  by  long  adhesions  to  the  ovary  and 
its  ligament,  and  the  ala  vespertilionis  on  that  side  was  thickened 
and  uneven,  as  if  from  old  deposits  of  lymph.  The  Fallopian  tubes 
were  pervious,  and  the  ovaries  w^ere  quite  healthy,  and  contained 
several  Graafian  vesicles. 

Between  the  aft'ection  we  are  now  studying  and  inflammation  of 
the  substance  of  the  ovaries  themselves  the  difi'erences  are  obvious 
and  manifold.  The  extreme  rapidity  with  which  matter  is  formed, 
and  the  large  quantity  of  it  which  is  secreted  in  so  short  a  time, 
are  not  compatible  with  the  seat  of  tlie  di.'^ease  in  the  substance  of 
an  organ  furnished  as  is  the  ovary  with  a  dense  fibrous  capsule, 
which,  though  elastic  and  admitting  of  vast  expansion  in  the  course 
of  time,  is  yet  not  capable  of  yiekling  so  as  to  allow  of  the  accu- 
mulation of  a  large  quantity  of  matter  in  a  few  days.  The  ter- 
mination of  ovaritis  by  supjiuration  is,  I  believe,  quite  excejjtioiuil. 
In  the  puerperal  stiite  it  is  the  [)eritoneal  investment  ol"  the  ovaries 
which  is  usually  affected;  while  when  inflammation  even  of  the 
acutest  kind  attacks  the  substance  of  those  organs,  and  ending  in 
the  formation  of  matter  proves  speedily  fatal,  it  does  not  lead  to 
any  great  increase  of  their  size,  but  to  sottening  and  complete  dis- 
integration of  their  tissue.  When,  in  other  circumstances,  large 
collections  of  matter  form  within  the  ovary,  their  origin  is  usually 


344  ANALOGIES    AND    SYMPTOMS 

traceable  to  some  cyst  in  whose  wall  inflammation  has  been  acci- 
dentally set  up;  and  such  ovarian  abscesses  generally  remain  for 
a  long  time  as  distinct,  well-circumscribed  tumors,  whose  contents 
are  very  slow  in  making  their  way  outwards.  Generally,  indeed, 
ovaritis  is  not  only  a  far  more  chronic  evil  than  inflammation  of 
cellular  tissue  about  the  womb,  and  is  attended  by  pain  of  a  very 
diflerent  character,  but  the  enlargement  of  the  organ  is  almost 
always  inconsiderable,  and  its  situation  is  often  inferred  from  pain 
produced  by  pressure  at  one  spot  rather  than  clearly  pointed  out 
by  any  considerable  increase  of  its  dimensions,  while  the  thicken- 
ing and  hardening  of  the  vaginal  walls,  scarcely  ever  absent  from 
that  side  of  the  canal  on  which  the  atfection  of  the  cellular  tissue 
is  situated,  is  never  met  with  in  cases  of  simple  ovarian  inflam- 
mation. 

The  analogies  of  this  affection  are,  I  believe,  rather  to  be  found 
among  those  inflammations  ol'tlie  cellular  tissue  which,  succeeding 
to  operations,  advance  with  great  rapidity,  and  terminating  soon  in 
the  formation  of  enormous  quantities  of  matter,  constitute  one  of 
the  most  untoward  of  those  accidents  by  which  the  skill  of  the 
surgeon  is  disappointed  of  best  merited  success.  The  rapid  forma- 
tion, and  occasional  rapid  disappearance  of  the  swelling,  show,  if 
further  proof  were  wanting,  that  it  is  not  due  to  changes  in  the 
solid  tissues  of  any  organ,  but  rather  to  osdenia  or  the  infiltration 
of  a  loose  tissue  with  fluid.  This  fluid,  too,  like  that  which  is 
formed  in  other  inflamnuitions  of  cellular  tissue,  is  not  at  first 
genuine  pus,  but  a  thin  sero-imrulent  matter,  and  often  still  retains 
this  character  long  after  it  has  been  formed  in  quantity  sufficient 
to  impart  to  tlie  finger  a  most  marked  sense  of  fluctuation. 

These  characters  then  correspond  to  those  of  difi'use  cellular 
inflammation,  or  "acute  purulent  oedema,"  as  it  has  been  well 
termed  by  the  distinguished  Russian  surgeon,  Pirogoft".'  It  we 
take  this  view,  which  he  indeed  suggests,  even  the  most  anomalous 
features  of  the  affection  will  become  comparatively  easy  to  under- 
stand. We  shall  not  be  sur}»rised  that  the  disease  should  occur  in 
the  weakly  rather  than  in  the  strong,  tliat  previous  hemorrhage  or 
other  debilitating  influences  should  favor  its  development,  that 
while  often  attended  b}'  comparatively  little  local  sufiering,  it 
should  yet  run  rapidly  through  its  earlier  stages;  but  still  now  and 
then  come  suddenly  to  a  standstill,  and  that  all  trace  of  it  should 
then  quickly  disappear.  Since  we  know,  too,  that  tlie  seat  of  the 
mischief  is  not  in  the  sexual  organs  themselves,  but  only  in  their 
connective  tissue,  we  shall  find  nothing  difiicult  of  explanation  in 
the  re-establishment  of  menstruation,  or  in  the  recurrence  of  preg- 
nane}', or  in  the  regular  performance  of  all  the  generative  func- 
tions, even  after  symptoms  which  had  seemed  most  formidable, 
and  had  appeared  as  though  they  must  imply  that  injury  had 
been  done  passing  the  power  of  nature  to  repair. 

In  those  cases  in  which  the  affection  succeeds  to  delivery  or 

1  Klinisclie  Chirurgie,  Drittes  Heft,  8vo.,  Leipzig,  1854,  pp.  3G-54. 


OF    THE    AFFECTION.  34§ 

abortion,  its  mode  of  attach  Reems  to  he  twofold.  Either  it  sets  in 
witli  well-marked  symptoms  of  constitutional  disorder,  such  as 
general  feverishness  and  heat  of  skin,  sometimes,  though  not 
olten,  preceded  by  shivering,  and  accom[)aiiied  by  abdominal  i)ain, 
which  is  seldom  very  intense;  or  else  it  comes  on  gradually,  the 
local  evil  being  developed  almost  imperceptibly  out  of  a  state  of 
incomplete  convalescence;  while  it  is  quite  an  exceptional  occur- 
rence for  severe  puerperal  peritonitis  to  precede  the  inflammation 
of  the  uterine  cellular  tissue.  In  the  majority  of  instances  th§ 
tenderness  and  pain,  though  referred  chiefly  to  the  lower  part  of 
the  abdomen,  are  not  at  lirst  distinctly  limited  to  one  or  other 
side,  and  not  infrequently  the  discovery  of  swelling,  induration, 
or  even  of  a  definite  tumor  in  one  or  other  iliac  region  by  the 
medical  attendant,  is  the  first  circumstance  which  directs  the 
patient's  notice  to  one  spot  as  the  special  seat  and  source  of  her 
sufterings.  The  sym[itoms  of  general  constitutiomd  disorder, 
even  when  most  marked  at  the  outset,  very  rarely  go  on  increas- 
ing in  severity  with  the  progress  of  the  local  mischief,  but,  hav- 
ing set  in  on  the  second  or  third  day  after  delivery,  subside  at  the 
end  of  a  fortnight  or  three  weeks.  This  subsidence  of  the  s3-mp- 
toms  often  takes  place  quite  independently  of  the  employment 
of  any  medical  treatment;  but  the  apparent  convalescence  tlms 
established  is  not  only  imperfect  from  the  first,  but  becomes  every 
day  more  and  more  interrupted,  as  the  local  ailment  advances, 
and  now,  if  not  earlier,  distinctly  manifests  itself  by  abdominal 
pain,  by  painful  micturition  or  defecation,  or  by  some  other  symp- 
tom which  clearly  points  to  its  situation. 

It  depends  upon  the  situation  of  the  affected  parts,  whether  or 
no  any  tumor  is  perceptible  externally;  for  while  always  more  or 
less  manifest  in  cases  where  the  parts  contained  within  the  broad 
ligament  are  the  seat  of  inflammation,  it  is  generallj'  absent  when 
the  mischief  is  limited  to  the  cellular  tissue  between  the  uterus 
and  bladder,  and  always  when  it  is  confined  to  the  parts  in  or 
about  the  recto-vaginal  septum.  Tlie  somewhat  vague  character 
of  the  symptoms  in  many  of  these  cases,  and  the  too  common 
neglect  of  vaginal  examinations,  lead  in  cases  of  this  description 
to  very  frequent  mistakes  as  to  the  nature  of  the  patient's  ailment, 
and  mistakes  all  the  less  excusable  since  there  are  few  ailments 
whose  diagnosis  is  more  simple  if  the  investigation  is  properly 
conducted.  It  is  not  easy  to  say  at  how  early  a  period  alter  the 
commencement  of  the  attack  a  swelling  forms,  so  as  to  be  detect- 
able on  examination  ;  but  my  impression  is,  that  tliough  often  not 
discovered  till  after  the  lapse  of  many  days,  it  usually  occurs  very 
speedily.  Careful  examination  even  two  or  three  days  after  the 
symptoms  began,  will  generally  ascertain  the  existence  of  fulness 
in  one  or  other  iliac  region,  will  find  that  on  ];»ressure  there  the 
complaint  of  })ain  is  greater  than  elsewhere,  and  that  percussion 
in  that  situation  yields  a  dull  sound,  and  conveys  a  sense  of  solidity 
not  perceptible  on  the  other  side.  In  such  circumstances,  local 
depletion  will  not  only  aflord  immediate  relief  to  the  patient's 


346  TENDENCY    TO    EARLY 

sensations,  but  that  relief  will  be  accompanied  by  a  disappearance 
of  the  swelling  so  complete  and  so  speedy  as  to  raise  a  momentary 
doubt  in  our  minds  as  to  whether  the  impression  of  its  existence 
was  not  a  mistake.  The  doubt,  however,  would  be  unfounded : 
the  swelling  was  very  real,  due  possibly  to  cedema  of  the  cellular 
tissue,  in  which,  but  for  our  treatment,  suppuration  would  soon 
have  taken  place,  as  indeed  it  does  in  the  great  majority  of  cases, 
and  then  condemns  the  patient  to  a  tedious  illness,  and  a  tardy 
convalescence.  The  same  rapid  formation,  and  rapid  disappear- 
ance of  the  swelling,  receive  another  illustration  in  cases  where  a 
sort  of  metastasis  of  the  inflammation  takes  place,  or  where,  to 
speak  more  correctly,  the  mischief,  originally  situated  on  one  side, 
attacks  without  apparent  cause  the  other  also ;  and  the  new  com- 
plaints of  pain  in  a  ditierent  situation  are  accompanied  by  tume- 
faction there,  which  may  be  very  temporary ;  or  may,  if  the  in- 
flammation there  advance,  become  as  solid,  and  prove  as  perma- 
nent as  that  on  the  other  side.  It  is  not  possible  to  fix  the  precise 
limits  of  time  within  which  resolution  ot  the  swellings  may  take 
place.  My  impression,  however,  is  that  the  period  is  very  short, 
and  that  after  the  lapse  of  a  few  days  at  furthest,  the  changes  are 
far  too  considerable  for  any  ra])id  cure;  and  that  pus  is  early 
formed,  though  the  processes  by  which  it  makes  its  way  to  the 
surface  are  generally  very  tardy,  and  those  are  slower  still  by 
which,  without  any  escape  of  matter  externally,  its  complete  ab- 
sorption is  now  and  then  eftected.  The  formation  of  matter  is  by 
no  means  invariably  followed  by  any  marked  increase  in  the  suf- 
ferings of  the  patient;  and  it  is  surprising  how  the  constitution 
bears  its  presence  even  in  considerable  quantities,  the  mechanical 
inconveniences  produced  by  the  pressure  of  the  abscess  being  not 
infrequently  those  from  which  the  patient  suflers  most,  and  which 
drive  her  at  length  to  seek  for  medical  assistance.  Thus,  a  young 
woman,  aged  twentj-five,  was  admitted  in  the  year  1849  into  St. 
Bartholomew's  Hospital,  having  been  ill  since  her  delivery  seven 
months  before.  On  the  ninth  day  after  her  confinement  she  was 
attacked  by  abdominal  inflammation,  the  more  acute  symptoms 
of  which  subsided  under  depletion,  and  she  attained  a  state  of 
imperfect  convalescence.  She  went  about  some  other  household 
duties,  though  with  difficulty,  and  even  cohabited  with  her  husband 
in  spite  of  the  i)ain  by  which  sexual  intercourse  was  attended. 
When  she  sought  for  admission  into  the  hospital  it  was  on  ac- 
count of  increased  difiiculty  in  micturition,  and  frequent  desire 
to  pass  water.  On  exiiminatiou  of  her  abdomen  an  oval  tumor 
was  discovered  in  the  mesial  line  reaching  midway  between  the 
symphysis  pubis  and  the  umbilicus,  and  produced  by  a  collection 
of  pus  in  the  cellular  tissue  between  the  uterus  and  bladder,  ten 
ounces  of  which  escaped  on  a  puncture  being  made  into  it  through 
the  vagiinil  wall.  The  patient  alleged  that  the  tumor  had  existed 
only  for  three  weeks ;  a  statement  which  can  scarcely  be  received  as 
correct,  since  she  had  never  thoroughly  recovered  from  the  illness 
which  followed  her  delivery ;  but  which  may  be  accepted  as  evi- 


OCCURRENCE  OF  SUPPURATION.  347 

dence  that  the  abscess  had  produced  no  special  effects,  till  by  its 
increased  size  it  began  mechanically  to  occasion  discomfort,  and 
to  interfere  painfully  with  the  functions  of  her  bladder. 

Another  illustration  of  the  same  fact  may  be  adduced  in  the 
person  of  a  young  woman  in  whom  constipation  from  the  fourth 
to  the  eighteenth  day  after  her  first  confinement  was  followed  by 
inflammation  of  the  cellular  tissue  behind  the  rectum.  The  action 
other  bowels  was  from  this  time  attended  by  great  pain,  and  cos- 
tiveness  alternated  with  diarrhtca,  the  evacuations  being  not  infre- 
quently intermixed  with  pus.  In  spite  of  these  symptoms,  how- 
ever, she  gradually  regained  her  general  health,  and  menstruation 
returned,  though  not  regularly.  Seventeen  months  after  her  con- 
finement she  had  been  visiting  the  Crystal  Palace,  in  Hyde  Park, 
and  while  returning  home  in  an  omnibus,  the  jolting  of  the  vehicle 
occasioned  the  sudden  bursting  of  an  abscess,  and  the  discharge 
of  about  three  pints  of  matter  streaked  with  blood  per  anura.  For 
the  next  three  months  from  that  time,  more  or  less  copious  puru- 
lent discharges  took  place  from  the  bowel,  behind  which  the  ab- 
scess whence  it  proceeded  was  situated,  forming  there  a  tumor  of 
about  the  size  of  a  small  apple.  Occasional  local  leeching  and 
the  most  sedulous  attention  to  the  state  of  the  bowels  were  suc- 
ceeded by  the  cessation  of  the  discharge,  and  the  ultimate  com- 
plete disappearance  of  the  tumor,  of  which  six  years  afterwards 
no  trace  existed. 

The  presence  of  any  collection  of  pus  so  considerable  as  that 
which  existed  in  these  two  cases  is  decidedly  unusual ;  but  though 
the  size  of  the  abscess  is  not  in  general  very  great,  it  not  infre- 
quently passes  into  a  chronic  state,  and  emptying  itself,  for  the 
most  part,  through  some  narrow  passage  of  communication,  into 
the  bowel,  the  patient  continues  for  months  or  years  liable  to  occa- 
sional discharges  of  pus  per  anum,  the  commencement  of  which 
dates  back  to  some  attack  of  inflammation  of  the  cellular  tissue 
years  before.  In  the  case  of  a  poor  woman  who  died  after  long 
suflTering  from  ulceration  of  a  quasi-malignant  character  about  her 
urethra  and  rectum,  a  collection  of  matter  was  found  in  the  midst 
of  the  thickened  and  condensed  cellular  tissue  by  the  side  of  the 
rectum,  and  between  it  and  the  uterus.  This  abscess,  too,  was 
lined  b}'  a  membrane  so  distinct,  so  smooth  and  polished,  as  for  a 
moment  to  raise  the  question  whether  it  was  not  a  distinct  cyst  in 
which  suppuration  had  been  accidentally  excited.  A  patient  was 
some  years  ago  under  my  care  in  whom  inflammation  of  the  cellu- 
lar tissue  between  the  uterus  and  rectum  having  gone  on  to  suppu- 
ration, it  was  considered  expedient  to  puncture  the  tumor  which 
was  found  in  the  vagina  Not  more  than  two  ounces  of  soro-puru- 
lent  fluid  were  evacuated  b}'  this  proceeding,  but  from  the  punc- 
ture flowed  for  the  ensuing  seven  weeks  many  ounces  of  pus  ilaily, 
its  quantity,  however,  diminishing,  and  the  discharge  at  length 
completely  ceasing  as  the  patient  advanced  towards  recovery,  and 
as  the  swelling  behind  her  womb  diminished.  In  another  instance, 
occasional  discharges  of  matter  took  place  from  the  bowel,  and 


348  DIAGNOSIS    OF    DIFFERENT 

pus  was  often  intermixed  with  the  faeces,  five  years  after  the  first 
symptoms  of  inflammation  of  tlie  cellular  tissue  about  the  uterus, 
the  chronic  results  of  which  were  still  evident  in  a  tumor  which 
was  closely  connected  lioth  with  the  rectum  and  the  womb.  Tliese 
chronic  abscesses  generally  contract,  and  the  fistulous  passages 
which  lead  to  them  become  by  degrees  obliterated,  but  exceptions 
to  this  now  and  then  occur,  two  of  which  have  come  under  my 
own  notice,  and  Dr.  Simpson^  has  reported  some  very  interesting 
cases  where  permanent  fistulous  communications  have  formed 
between  the  abscess  succeeding  to  inflammation  of  the  pelvic  cel- 
lular tissue,  and  the  bladder,  uterus,  or  intestinal  canal. 

Often,  though  perhaps  not  always,  the  formation  of  abscesses 
having  so  chronic  a  character  as  those  to  which  reference  has  just 
been  made,  might  be  prevented  if  the  nature  of  the  ailment  were 
recognized  at  the  commencement.  The  ch'ngnosis,  too,  is  not  at- 
tended by  much  ditficulty  if  only  it  is  borne  in  mind  that  whenever 
after  delivery  or  miscarriage  ill-defined  febrile  symptoms  occur, 
accompanied  by  abdominal  pain,  inflammation  in  the  vicinity  of 
the  uterus  is  probably  present,  and  this  even  though  the  constitu- 
tional disturbance  should  not  be  considerable,  nor  the  pain  expe- 
rienced by  any  means  severe.  If  now  the  inflammation  is  seated 
in  the  broad  ligament,  there  will  at  first  be  found  in  one  or  other 
iliac  region  a  vague  sense  of  fulness;  percussion  in  that  situation 
yielding  a  dull  sound,  and  pressure  being  painful;  and  afterwards 
a  more  definite  swelling.  At  no  time,  however,  is  this  swelling 
so  circumscribed  that  its  border  can  be  distinctly  traced,  nor  is  it 
movable  like  a  fibrous  tumor  of  the  womb,  or  an  enlarged  ovary, 
but  it  is  felt  like  a  hard  mass,  extending  laterally  to  the  inner 
surface  of  the  pelvic  wall,  and  firmly  adherent  to  it,  reaching 
down  into  the  pelvic  cavity  so  that  its  lower  border  cannot  be 
felt,  while  its  upper  and  inner  margin  are  both  but  vaguely 
marked;  the  thickening  in  those  situations  seeming  rather  to 
pass  away  by  degrees  than  suddenly  to  cease.  The  dimensions 
of  this  swelling  are  always  much  more  considerable  from  side  to 
side  than  from  below  upwards;  dittering  in  this  respect  from 
tumors  of  the  uterus  or  ovaries;  its  surface  is  even,  but  extremely 
hard;  it  seems  very  superficial;  the  abdominal  walls  are  not  readily 
movable  over  it,  but  often  seem  as  though  they  were  adherent  to 
it.  This,  too,  they  doubtless  are  in  some  cases,  but  the  same  sen- 
sation is  very  often  communicated  to  the  hand  in  instances  where 
there  is  no  reason  whatever  for  supposing  that  adhesion  has  taken 
place  between  the  opposite  surfaces  of  the  peritoneum,  while  fur- 
tlier,  the  rapidit^^  with  which  in  some  cases  the  apparent  union  is 
dissolved,  shows  that  it  must  have  depended  on  some  cause  of  a 
much  more  temporary  nature.  My  impression  is,  that  it  is  in  a 
measure  due  to  oedema  of  the  cellular  tissue  between  the  abdom- 
inal muscles  and  the  peritoneum;  a  condition  which  not  infre- 
quently terminates  in  suppuration,  and  thus  constitutes  what  has 

1  Obstetric  Memoirs,  vol.  i,  p.  232. 


FORMS    OF    THE    AFFECTION,  349 

been  termed  external  'peritonitis,  but  which  hi  many  cases  is  but 
an  attendant  on  inflammation  of  the  more  deeply-seated  tissues, 
increasing  as  that  advances,  remaining  stationary  wlien  that  ccmies 
to  a  standstill,  and  rapidly  disa])pearing  as  that  begins  to  subside. 
An  obvious  lessening  of  the  general  fulness  of  the  abdomen,  and 
a  sense  of  mobility  of  the  abdominal  walls  over  the  tumor,  is  one 
of  the  first  signs  of  the  patient's  amendment,  and  one  which  often 
long  precedes  any  alteration  in  .the  size  or  contour  of  the  swelling ; 
while  next,  as  its  size  lessens,  the  previous  adhesions  between  it 
and  the  pelvic  wall  become  less  firm,  and  its  chief  connection  is 
felt  to  be  not  with  tlie  side  of  the  pelvis,  but  with  some  body  at 
its  centre  ;  in  other  words,  with  the  uterus  itself.  Up  to  the  last, 
the  indistinctness  of  outline  which  has  been  already  noticed  as 
characteristic  of  these  swellings  continues  to  distinguish  them, 
and  a  vao-ue  sense  of  fulness  in  the  iliac  region  remains  long  after 
all  other  evidence  of  their  presence  has  ceased. 

When  suppuration  takes  place,  the  matter  makes  its  way  out- 
Avardly  through  the  vagina,  or  through  the  intestinal  canal,  in 
almost  all  cases  in  which  the  inflammation  is  limited  to  the  parts 
contained  within  the  broad  ligaments.  In  those  cases,  however, 
in  which  the  pelvic  cellular  tissue  is  implicated,  the  matter  not 
infrequently  makes  its  way  round  between  the  muscles  and  the 
external  surface  of  the  peritoneum,  and  the  abscess  points  and 
discharges  itself  through  the  abdominal  walls  somewhere  in  the 
course  of  Poupart's  ligament,  or  a  little  below  that  situation.  It 
sometimes  happens,  however,  that  even  after  fluctuation  has  be- 
come distinctly  perceptible  through  the  abdominal  walls,  the 
abscess  eventually  bursts  either  through  the  vagina  or  the  rectum, 
and  in  one  instance  a  communication  formed  apparently  al)out 
the  situation  of  the  sigmoid  flexure  of  the  colon  ;  and  after  the 
escape  of  matter  by  the  bowel,  air  was  for  many  days  distinctly 
perceptible  in  the  sac  of  the  abscess. 

In  cases  of  uncomplicated  external  peritonitis,  and  also  in  those 
where  inflammation  in  this  situation  occurs  simultaneously  with 
that  of  more  deep-seated  parts,  the  tendency  naturally  is  to  the 
escape  of  matter  externally.  The  swelling  in  cases  of  external 
peritonitis  is  harder  and  tenser  than  when  the  mischief  is  more 
deeply  seated,  the  integuments  become  red,  shining,  and  brawny, 
and  this  condition  extends  lower  down  than  when  the  inflamma- 
tion is  seated  in  the  parts  within  the  folds  of  the  broad  ligament, 
and  reaches  quite  into  the  inguinal  region.  The  quantity  of 
matter  formed  in  these  cases  usually  amounts  to  several  ounces  ; 
the  abscess  pointing  at  one  spot,  and  the  whole  of  its  contents 
escaping  at  a  single  aperture.  Sometimes,  however,  in  cases  where 
inflammation  of  the  uterine  or  pelvic  cellular  tissue  is  present,  the 
tissue  external  to  the  pcritcmeum  becomes  aftected  secondarily  ; 
not  by  direct  extension  of  the  mischief  to  it,  but  rather  l)y  a  s^rt 
of  sympathy,  and  in  this  case  two  or  three  small  circumscrihed 
collections  of  matter  are  not  infrequently  formed,  each  of  which 
may  require  to  be  separately  evacuated. 


350  DIAGNOSIS    OF    THE    AFFECTION. 

An  examination  per  vaginam  throws  additional  liglit  upon  the 
case,  except  of  course  in  those  instances  in  which  the  external  sur- 
face of  the  peritoneum  is  alone  affected.  The  vagina  is  hot,  and 
puffy,  and  tender  ;  and,  according  to  the  seat  of  the  inflammation, 
either  its  anterior  or  its  posterior  wall  is  felt  to  he  thickened,  and 
hard  like  brawn  ;  and  the  uterus  itself  is  fixed  hy  this  thickening 
of  the  vagina  more  or  less  completely  in  the  pelvis,  and  at  the  same 
time  is  carried  hy  means  of  it  higher  up  than  natural,  so  as  not  to 
come  as  readily  as  usual  within  reach  of  the  exploring  finger.  As 
the  cellular  tissue  within  the  folds  of  the  broad  ligament  is  oftener 
affected  than  that  in  any  other  situation,  so  it  is  at  the  roof  of  the 
vagina,  towards  one  or  other  side,  and  commonly  extending  some- 
what round  behind  the  uterus,  that  these  characters  are  most 
marked.  Soon,  too,  a  distinct  tumor  is  perceptible  in  addition  to 
the  general  thickening,  swelling,  and  hardness  of  the  vaginal  wall, 
and  the  swelling,  if  considerable,  pushes  over  the  uterus  towards 
the  opposite  part  of  the  pelvis.  If  seated  at  the  side  it  does  not 
in  general  dip  down  dee])ly  into  the  pelvic  cavity,  and  though  it 
ma}'  he  seized  between  the  hand  externally,  and  the  fingers  in  the 
vagina,  the  state  of  the  abdominal  integuments,  and  the  thickening 
of  the  roof  of  the  vagina  interfere  with  the  accurate  determination 
of  its  size  and  contour.  If  the  mischief  extends,  as  often  happens, 
either  in  front  or  behind,  a  definite  swelling  is  very  likely  to  be 
formed,  and  this  swelling  is  usually  larger  and  more  distinctly 
circumscribed  when  situated  behind  the  uterus  than  when  occupy- 
ing the  cellular  tissue  in  front  of  the  organ.  If  the  cellular  tissue 
between  the  uterus  and  bladder,  and  along  the  anterior  vaginal 
w^all,  is  the  seat  of  the  inflammation,  we  may  then  find  the  hardened, 
thickened,  tumefied  state  of  the  vagina  reaching  down  to  its  very 
outlet,  and  the  os  uteri  pushed  quite  out  of  reach  by  a  swelling  in 
front  of  it,  not  distinctly  circumscribed,  but  passing  over  into  the 
substance  of  the  thickened  anterior  vaginal  wall.  If  au}^  laige 
quantity  of  pus  is  formed  in  this  situation,  it  does  not  commonly 
seem  to  increase  very  much  the  size  of  the  pelvic  tumor,  but  forms 
a  distinct,  well-defined  swelling  between  the  uterus  and  bladder, 
which  rises  up  out  of  the  ])elvic  cavity,  and  may  be  felt  through 
the  abdominal  walls,  occupying  the  situation,  aiul  having  much  the 
contour  of  the  half-distended  bladder.  It  is  when  seated  behind 
the  uterus,  on  the  other  hand,  that  tlie  occurrence  of  suppuration 
is  apt  to  give  rise  to  the  most  definite  pelvic  tumor ;  for  there  is 
in  this  situation  a  greater  obstacle  than  elsewhere  to  the  extension 
of  the  swelling  upwards  out  of  the  pelvis,  while  the  cellular  tissue 
in  the  recto-vaginal  septum  is  looser  and  more  abundant  than 
anywhere  else  in  the  immediate  vicinity  of  the  uterus.  Here  then 
matter  very  speedily  forms,  and  gives  rise  to  a  swelling  which  oc- 
cupies the  whole  posterior  part  of  the  pelvis,  bulging  out  into  it, 
just  as  an  ovarian  tumor  is  apt  to  do  when  seated  in  the  recto- 
vaginal pouch,  but  more  elongated  in  form,  less  globular,  and 
while  generally  tense,  yielding  usually  at  one  spot,  perceptible 
through  the  vagina  or  through  the  rectum,  a  peculiar  boggy  sen- 


ITS    ORDINARY    COURSE.  351 

sation,  suggestive  of  a  thinning  of  its  covering  having  taken  place 
there,  and  of  matter  being  likely  to  escape  in  that  situation.  The 
OS  uteri,  too,  will  be  found  to  be  carried  out  of  reach  more  com- 
pletely than  it  would  be  by  an  ordinary  ovarian  cyst  of  equal  di- 
mensions, and  the  tumor  itself  to  reach  lower  down,  nearer  to  the 
orifice  of  the  vulva,  since,  it  is  not  a  mere  swelling  seated  in  the 
recto-vaginal  pouch,  but  is  ibrmed  in  the  substance  of  the  septum 
itself,  where  the  matter  naturally  gravitates  lower  and  lower. 

I  do  not  know  of  any  error  which  with  moderate  care  can  be 
committed  as  to  the  nature  of  these  swellings,  except  in  the  rare 
cases  of  extravasation  of  blood  into  the  cellular  tissue  behind  the 
uterus,  uterine  hcemafocele,  as  it  has  been  called;  and  in  them  the 
tumor  very  closely  resembles  that  produced  by  suppuration  in  the 
same  situation.  The  suddenness  of  the  attack  of  uterine  ha^ma- 
tocele,  its  independence  of  delivery  or  abortion,  and  the  general 
absence  of  thickening  and  hardening  of  the  vaginal  wall  around 
the  swelling,  will,  I  should  imagine,  usually  enable  us  to  discrimi- 
nate between  them;  while  happily  there  is  no  serious  practical 
error  to  which  a  mistaken  diagnosis  would  give  occasion. 

It  is  scarcel}'  necessary  to  trace  the  further  prof/rens  of  these 
sioellivgs,  except  perhaps,  to  add  two  cautions:  first,  that  the  sense 
of  fluid  being  contained  within  them  is  not  infrequently  deceptive, 
so  far  at  least  that  it  would  seem  to  imply  in  many  instances  the 
existence  of  a  state  of  general  oedema  of  the  cellular  tissue,  and  not 
such  a  definite  collection  of  matter  as  could  be  evacuated  by  the 
trocar;  and,  second,  that  even  after  the  actual  evacuation  of  pus, 
tliere  is  seldom  that  immediate  and  great  diminution  of  the  swelling 
which  we  might  beforehand  anticipate;  but  the  thickening  of  the 
cellular  tissue  which  remains  behind  is  not  only  considerable,  but 
is  many  months  before  it  is  entirely  removed. 

The  sym[)toms  of  the  disease,  even  after  it  is  fully  established, 
and  after  the  formation  of  a  distinct  tumor  has  taken  place,  are 
not  in  general  of  a  very  definite  character.  The  patient's  condition 
is  one  of  weakness,  illness,  feverishness,  with  evening  exacerba- 
tions, restless  nights,  and  morning  remissions,  rather  than  one 
either  of  very  great  local  suft'ering  or  very  urgent  constitutional 
disturbance,  though  when  the  atfection  has  lasted  very  long,  and 
is  telling  severely  on  the  patient's  powers,  diarrhoea  not  infrequently 
comes  on,  and  tlie  fever  assumes  a  marked  hectic  character.  The 
local  suffering  varies  much,  according  to  the  part  which  is  chiefly 
aftected;  the  sense  of  bearing  down  being  most  distressing  when 
the  recto-vaginal  tissue  is  involved,  and  the  frequent  uccmI  of 
micturition  most  troublesome  when  the  tissue  between  the  uterus 
and  bladder  is  the  seat  of  inflammation.  In  all  instances,  how- 
ever, the  bladder  sympathizes  more  or  less  with  the  inflammation 
in  its  vicinity,  and  some  degree  of  dysuria  and  over-frequent 
micturition  are  symptoms  scarcely  ever  absent.  While  in  all 
cases,  be  the  exact  seat  of  the  mischief  what  it  may,  there  is  more 
or  less  pain  referred  to  the  pelvis,  more  or  less  tenderness  on 
pressure  upon  the  abdomen,  the  amount  of  severe  suft'ering  varies 


352       ORDINARY  COURSE  OF  THE  AFFECTION. 

very  considerably,  and  varies,  too,  without  any  very  obvious  cause. 
A  dull  pain,  a  sense  of  weiglit,  and  a  burning  sensation  seem  to 
be  constant,  while  very  severe  snliering  is  often  produced  by  the 
attempt  to  stand,  or  even  to  sit  up.     Sometimes,  too,  independent 
of  any  exciting  cause,  paroxysms  of  pain  occur,  of  extreme  vio- 
lence, which  last  for  an  hour  or  two,  and  then  subside,  returning 
the  next  day,  or  sooner,  being  equally  violent,  and  passing  off 
again  of  their  own  accord.     The  severest  suftering  generally  takes 
place  before  the  presence  of  matter  in  the  swelling  has  become 
distinct,  while  afterwards,  during  the  long  period  which  oiten 
elapses  previous  to  the  contents  of  the  abscess  finding  an  outlet, 
though  the  constitutional  disorder  may  become  more  serious,  the 
local"  pain  generally  abates.     With  the  escape  of  the  matter  the 
relief  obtained  is  usually  far  more  decided,  though  this  seldom 
occurs  in  a  sudden  gush,  so  as  to  give  instant  ease,  but  the  aperture 
of  communication  with  the  abscess  being  very  small,  the  matter  for 
the  most  part  escapes  only  in  small  quantities;  or  being  poured  out 
into  the  rectum,  collects  there  till  a  few  ounces  have  accumulated, 
and  are  expelled  during  some  etfort  at  defecation;  while  for  days 
or  weeks  afterwards  pus  is  intermingled  with  the  faeces,  or  a  small 
discharge  of  it  precedes  their  passage.     In  cases  where  the  cellular 
tissue  between  the  folds  of  the  broad  ligament  is  the  seat  of  the 
inflammation,  as  well  as  in  those  where  the  tissue  behind  the  uterus 
is  affected,  the  escape  of  the  matter  generally  takes  place  through 
the  rectum  ;  very  rarely  indeed  through  the  vagina.     The  aperture 
of  communication  with  the  bowels  is  usually  low  doAvn,  though 
above  the  internal  sphinctei',  and  though  conmionly  too  minute  to 
be  detected,  its  situation  may  be  guessed  with  tolerable  accuracy, 
as  the  finger  discovers  some  spot  in  the  swelling  where  its  parietes 
are  soft  and  jnelding.     Once  an  iliac  abscess  on  the  left  side,  in 
which  fiuctuution  was  distinctly  perceptible,  while  the  redness  of 
the  abdominal  integuments,  and  their  firm  connection  with  the 
swelling,  led  one  to  expect  that  it  would  discharge  itself  externally, 
burst  into  the  intestine,  and  the  communication  was  free  enough 
to  allow  of  the  entrance  of  air  into  the  sac  of  the  abscess,  in  which 
situation  crepitation  continued  for  days  to  be  distinctly  felt.     In 
the  meantime  suppuration  went  on  in  the  tissue  beneath  the  ab- 
dominal muscles,  and  a  distinct  abscess  formed  there,  which  was 
afterwards  evacuated  by  the  knife.     Twice  also  I  saw  an  abscess' 
discharo-e  itself  throuo-h  the  bladder,  though  this  occurrence  was 
not  final  in  either  case;  for  in  the  one  an  abscess  formed  exter- 
nally, and  in  the  other  it  burst  likewise  into  the  intestinal  canal, 
and  the  patient  sutfered  for  several  weeks  irom  diarrhoea,  with 
discharge  of  pus  per  anum.     In  these  cases,  however,  and  also  in 
others  in  which  after  an  abscess  has  pointed  or  has  actually  burst 
in  one  situation,  matter  afterwards  makes  its  escape  in  another,  it 
is,  I  think,  very  doubtful  whether  both  discharges  took  place  from 
the  same  source,  or  whether  there  have  not  been  two  distinct  ab- 
scesses perfectly  independent  of  each  other,  and  one  anterior  to 
the  other  in  the  date  of  its  formation.     The  disposition  of  this 


EXCEPTIONAL    CASES.  353 

affection  not  simply  to  extend  by  direct  continuity  of  tissue,  but 
also  to  attack  similar  structures  even  when  not  immediately  con- 
nected, is  a  feature  of  the  complaint  to  whicli  reference  has  already 
been  made,  and  one  which  adds  much  to  its  gravity,  and  imposes 
on  us  the  necessity  of  watching  our  patients  most  sedulously  for 
a  long  time  after  they  have  seemed  to  be  fairly  in  the  way  to  con- 
valescence. 

The  gradual  progress  of  the  patient  towards  recovery  during  the 
continuance  of  discharge  from  the  abscess,  and  the  slow  processes 
by  which  the  thickening  and  induration  of  the  affected  parts  are 
by  degrees  removed,  are  unattended  by  symptoms  calling  for  special 
description.  Their  history  is  one  of  a  convalescence  as  irksomely 
slow  in  some  instances,  as  in  other  cases  where  the  mischief  having 
been  seen  and  understood,  and  appropriate  treatment  having  been 
early  adopted,  it  is  surprisingly  rapid.  The  disposition  to  relapse, 
too,  to  the  reproduction  of  fresh  mischief  in  its  old  seat,  or  to  the 
kindling  of  inflammation  in  some  part  previously  unaffected,  is 
never  to  be  lost  sight  of,  both  as  governing  our  prognosis  and  as 
regulating  our  treatment. 


LECTURE   XXIII. 

DISEASES  OF  PAKTS  CONNECTED  WITH  THE  IJTERUS— INFLAM- 
MATION AND  ITS  RESULTS,  AND  KINDEED  TEOCESSES. 

Inflammation  of  Utekine  Appendages  :  of  the  Cellular  Tissue. 

Exceptional  cases,  consequent  on  ])ei-itouitis  without  special  uterine  disorder  ;  im- 
))ortant,  but  apt  to  be  overlooked. 

Treatment  in  recent  stage,  care  during  convalescence.  ^  In  chronic  stage;  question 
of  puncture,  delay  generally  advisable ;  treatment  of  sequelaj. 

Hf-morrhage  about  Uterus,  or  Uterine  Hematocele.  Seat  and  causes  of 
extravasation  of  blood.  Sjnnptoms  and  course,  changes  in  the  eft'used  blood  ; 
cases  in  illustration.  Diagnosis;  from  extra-uterine  pregnancy,  from  retrover- 
sion of  the  uterus,  from  pelvic  abscess,  from  ovarian  tumor,  and  from  fibrous 
tumor  of  the  uterus.     Prognosis  and  causes  of  death. 

Treatment ;  comparative  merits  of  interference  and  exi:)ectancy. 

In  all  the  cases  of  inflammation  of  the  cellular  tissue  in  the 
vicinity  of  the  uterus  which  engaged  our  attention  in  the  last 
lecture,  the  disease  was  spoken  of  as  succeeding  to  delivery  or 
miscarriage.  In  such  cases  the  disorder  of  the  puerperal  processes 
by  which  it  is  accompanied  usually  gives  to  the  attentive  observer 
early  notice  of  its  occurrence.  The  affection  may,  however,  come  on 
quite  inilcpendently  of  puerperal  causes,  and  may  sometimes,  though 
I  believe  rarely,  be  wholly  unconnected  with  any  previous  disorder 
of  the  uterus,  or  with  any  previous  disturbance  of  its  function^. 

In  cases  of  this  last  description,  the  local  ailment  seems  usually 
to  develop  itself  out  of  the  symptoms  of  a  general  peritonitis  of 
no  very  great  severity,  which,  though  relieved  by  treatment,  have 

23 


354  EXCEPTIONAL    CASES. 

not  altogether  disappeared,  but  liavc  become  limited  in  extent,  and 
have  been  referred  to  the  uterus  and  the  pelvic  region,  where  a 
careful  examination  discovers  just  the  same  changes  to  have  taken 
place  as  succeed  to  inflammation  in  the  puerperal  state. 

A  woman  aged  thirtj^-nine,  married  twenty-one  years,  thrice 
pregnant,  her  youngest  child  being  eleven  years  old,  was  attacked, 
while  following  her  occupation  at  a  mangle,  by  sickness,  retching, 
and  pain  in  the  abdomen,  severest  at  its  lowest  part.  She  kept  her 
bed  for  a  week,  then  attended  at  the  out-patient  room  of  the  hospital 
for  ten  days,  during  which  time  leeches  were  applied  to  the  abdo- 
men ;  and  being  afterwards  admitted  as  an  inpatient,  she  was 
further  depleted,  and  subjected  to  a  mercurial  treatment,  by  which 
her  mouth  was  made  slightly  sore.  Her  severer  symptoms  were 
relieved  by  these  means,  but  as  she  was  not  cured  she  was  trans- 
ferred to  my  care  at  the  end  of  ten  days  more,  or  just  a  month  from 
the  commencement  of  her  illne^<s.  At  this  time  she  complained  of 
very  severe  pain  at  the  lower  part  of  her  abdomen,  extending  to  her 
back,  and  increased  in  parox^'sms  that  came  on  causelessly;  as 
well  as  of  constant  sickness  after  taking  anj-  food  or  drink,  and  of 
troublesome  diarrhoea.  Iler  abdomen  was  distended  and  generally 
tympanitic,  but  percussion  yielded  a  dull  sound  in  the  right  iliac 
region,  though  there  was  no  distinct  tumor  to  be  there  discovered. 
The  uterus  was  found  on  a  vaginal  examination  carried  forward, 
and  to  the  right  side,  bj  a  tumor  of  stony  hardness,  smooth  sur- 
face, and  globular  form,  extending  from  near  the  left  sacro-iliac 
synchondrosis,  pushing  the  rectum  before  it  and  to  one  side,  and 
occupying  a  great  part  of  the  pelvic  brim.  Tenesmus  and  pain 
accompanying  the  Irequent  eflorts  at  defecation  were  for  a  time 
very  distressing,  but  the  appearance  of  pus  in  the  evacuations,  and 
its  occasional  discharge  by  the  bowel  unmixed  with  feeces,  were 
followed  at  the  end  of  a  week  by  much  relief.  At  the  end  of  six 
weeks  the  patient  left  the  hospital,  the  tumor  being  much  dimin- 
ished, and  the  uterus  having  returned  more  nearly  to  its  natural 
position,  though  being  still  firmly  fixed  in  the  pelvis,  as  indeed  it 
continued  thirteen  months  afterwards. 

In  tliis  case  the  opportunity  was  afforded  of  watching  the  evil 
while  still  in  progress,  but  accident  sometimes  brings  cases  before 
us  where,  though  the  mischief  already  done  is  extensive,  we  can 
gather  but  little  information  as  to  the  circumstances  in  which  it 
originated.  Inquiry  may  perhaps  elicit  a  vague  history  of  fever, 
or  of  an  illness  accompanied  by  disorder  of  the  bowels,  or  by 
abdominal  pain,  but  unattended  as  far  as  the  patient  knows  by 
uterine  ailment ;  and  yet  the  womb  may  be  firmly  fixed  in  the 
pelvis,  and  thickening  of  the  adjacent  parts  may  plainly  show  that 
at  some  distant  period  the  cellular  tissue  in  its  vicinity  had  been 
the  seat  of  serious  inflammation.  In  such  cases  there  is  no  reason 
for  doubting  our  patient's  veracity ;  the  symptoms  of  the  slighter 
ailment  were  masked  by  those  of  the  more  grave  disease,  or  perhaps 
were  really  by  no  means  urgent  in  their  character,  and  were 
reigarded  as  only  the  ordinary  discomforts  of  a  tedious  convales- 


TllEATMENT    OF    THE    AFFECTION.  355 

ceiicc.  Tliey  are  of  great  practical  importance,  as  illustrations 
of  the  necessity  for  watching  very  carefully  the  convalescence  of 
patients  who  have  been  the  subject  of  any  illness  in  the  course 
of  which  abdominal  inflanmiation  may  by  possibility  occur.  The 
mischief  may  perhaps  not  entirely  pass  away,  but  with  a  few  signs  to 
betray  its  existence,  may  become  limited  to  parts  within  the  pelvis. 
It  may  then  be  confined  to  the  peritoneal  surface  of  the  viscera, 
matting  the  difi'erent  organs  together  by  firm  adhesions,  which 
interfere  Avith  the  elevation  of  the  uterus  out  of  the  pelvic  cavity, 
and  thus  in  the  event  of  pregnancy  occurring  give  occasion  to  its 
premature  termination,  though  absolute  sterility  is  by  no  means 
an  infrequent  consequence  of  the  attack.  Or,  instead  of  being 
limited  to  the  peritoneum,  the  inflammation  may  chiefly  affect 
the  celkilar  tissue  in  the  vicinity  of  the  uterus,  and  may  issue  in 
suppuration,  or  in  deposit  and  permanent  thickening,  which  may 
remain  long  after  the  acute  disease  is  over,  sometimes  even  after 
the  memor}'  of  it  has  almost  passed  away.  It  behooves  us  then  to 
bear  these  risks  in  mind,  not  to  take  the  decline  of  the  symptoms 
in  such  cases  as  a  certain  pledge  of  their  complete  disappearance; 
but  so  long  as  there  is  any  pain  or  discomfort  referred  to  the 
lower  part  of  the  abdomen  or  the  neighborhood  of  the  uterus,  to 
have  our  suspicions  alive  to  the  possible  occurrence  either  of  cir- 
cumscribed peritonitis,  or  of  inflammation  of  the  cellular  tissue 
connected  with  the  womb  or  its  appendages. 

In  considering  the  treaUnent  of  this  aifcction,  we  must  bear  in 
mind  the  difference  between  the  results  likely  to  be  obtained  before 
suppuration  has  taken  place  and  after  it  has  occurred.  h\  the 
former  case,  a  few  days  will  suflGice  for  the  complete  removal  of  all 
traces  of  disease;  in  the  latter,  weeks  or  months  will  often  'issue 
in  but  a  very  incomplete  recovery,  Whether  treated  in  its  acute 
or  in  its  chronic  stage,  indeed,  our  prognosis  may  almost  always 
be  favorable  as  far  as  the  life  of  the  patient  is  concerned.  AV'hen 
the  disease,  however,  is  of  long  standing,  iMs  idle  to  attem})t  any 
reply  to  inquiries  as  to  the  probable  duration  of  the  patient's  ill- 
ness, or  as  to  the  time  that  must  elapse  before  the  pelvic  organs 
return  to  their  previous  state,  and  to  the  regular  performance  of 
their  wonted  functions. 

It  is  not  a  heroic  plan  of  treatment,  however,  which  is  necessary 
when  we  see  the  disease  at  its  onset,  in  order  to  cut  short  its  further 
progress.  A  dozen  leeches  applied  to  whichever  iliac  region  is  the 
seat  of  pain  ;  a  warm  poultice  frequently  renewed,  and  continued 
for  thirty-six  or  forty-eight  hours,  a  gentle  aperient,  some  mild 
febrifuge  medicine,  and  opiates  to  subdue  pain,  and  to  insure  for 
the  patient  quiet  rest  at  night,  with  a  generally  mild  and  uiistim- 
ulatiiig  diet,  are  the  simple,  and  as  I  believe,  the  fully  suillcient 
means  by  which  the  symptoms  may  be  combated.  tSliould  the 
pain  and  tenderness  not  be  removed  by  the  first  depletion,  half  a 
dozen  leeches  ought  to  be  reapplied  within  the  next  twenty-four 
hours  ;  but  the  frequent  ahstraction  of  blood  is  undesirable.  The 
tenderness  and  pain  which  sometimes  remain  even  after  blood  has 


356  TREATMENT     OF 

been  drawn  to  as  great  an  extent  as  seems  expedient,  and  which 
are  often  accompanied  by  considerable  fulness  of  the  affected  side, 
are  generally  much  relieved,  often  altogether  removed,  by  the 
application  of  an  ointment  composed  of  two  drachms  of  extract  of 
belladonna  and  six  drachms  of  mercurial  ointment,  which  may  be 
thickly  spread  on  lint,  covered  with  oiled  silk,  and  renewed  every 
twent3'-four  hours.  The  relief,  too,  is  obtained  quite  independ- 
entlv  of  the  production  of  any  specific  mercurial  influence  on  the 
system.  If,  in  addition  to  tlie  pain  at  one  or  the  other  side  of  the 
abdomen  there  should  be  difficulty  in  micturition,  or  tenesmus, 
or  bearing  down,  or  much  pelvic  pain  or  discomfort,  it  is  probable 
that  a  vaginal  examination  will  discover  the  mischief  not  to  be 
limited  to  the  uterine  appendages,  but  to  involve  the  cellular  tis- 
sue between  the  uterus  and  rectum,  or  between  that  organ  and 
the  bladder.  In  this  case  the  application  of  four  or  six  leeches  to 
the  uterus  itself,  by  means  of  the  speculum,  will  often  afford  an 
amount  of  relief  that  Avould  be  vainly  sought  for  by  the  employ- 
ment of  four  times  their  number  if  put  on  externally. 

After  all  general  febrile  disturbance  has  subsided,  and  when 
nothing  remains  but  a  little  local  pain  and  tenderness,  and  per- 
haps some  stiffness  in  the  limb  of  the  affected  side,  the  application 
of  a  small  blister,  so  as  scarcely  to  vesicate,  will  often  yield  great 
relief,  and  this  may  be  repeated  two  or  three  times,  at  intervals 
of  as  many  days  ;  its  situation  being  varied  just  sufficiently  to  ob- 
viate the  production  of  a  troublesome  sore.  In  many  instances, 
however,  if  the  case  is  seen  quite  at  the  outset,  the  symptoms  dis- 
appear at  once  after  a  single  application  of  leeches,  and  our  chief 
difficulty  then  consists  in  persuading  our  patient  to  submit  to  those 
restrictions,  and  to  observe  those  precautions  which  may  seem  to 
her  to  be  dictated  by  our  over-carefulness  ratherthan  by  the  actual 
necessities  of  her  case.  The  avoidance  of  fluctuations  of  tempera- 
ture, and  of  premature  exertion  of  any  kind,  is  indeed  a  matter  of 
the  greatest  possible  importance  during  the  whole  period  of  con- 
valescence. So  long  as  there  are  any  considerable  remains  of 
pain,  or  as  there  is  much  tenderness  on  pressure  in  the  iliac  re- 
gion, or  over  the  pubes,  it  is  unsafe  for  the  patient  to  leave  her 
bed,  or  even  to  move  much  from  the  recumbent  posture ;  for  there 
is  risk,  not  simply  of  a  very  slight  cause  producing  an  exacerba- 
tion of  the  inflammation  at  its  original  seat,  but  also,  as  has  been 
alread}^  explained,  of  mischief  attacking  the  opposite  side.  ISTow 
and  then,  too,  phlegmasia  dolens  has  come  on  under  my  observa- 
tion in  cases  where  all  active  symptoms  had  already  passed  away, 
and  where  no  special  cause  could  be  assigned  for  its  occurrence. 
Even  after  complete  recovery,  the  return  of  menstruation,  or  even 
of  the  period  at  which  the  menses  ought  to  occur,  calls  for  fresh 
solicitude,  and  any  recurrence  of  pain,  or  even  of  uneasiness,  any 
rekindling  of  febrile  disturbance,  must  be  at  once  met  by  a  repeti- 
tion of  local  bleeding,  and  a  renewal  of  former  precautions  and 
former  treatment. 

Unfortunately,  in  the  great  majority  of  cases,  the  evil,  before  it 


.  THE    AFFECTION.  357 

attracts  attention,  or  receives  appropriate  treatment,  lias  advanced 
further,  and  there  is  not  merely  a  general  sense  of  fulness  at  one 
side  of  the  abdomen  where  the  patient  complains  of  pain,  but  a 
distinct  tumor  is  already  perceptible  on  external  or  internal  ex- 
amination. In  these  circumstances  a  speedy  recovery  can  no 
longer  be  anticipated,  but  something  may  still  be  done  to  prevent 
any  abundant  formation  of  matter,  to  favor  the  absorption  of  the 
sero-purulent  fluid  alread}"  poured  out,  and  to  bring  aljout  the 
resolution  of  the  tumor.  The  application  of  leeches  is  as  appro- 
priate here  as  in  the  earlier  stages  of  the  complaint,  though,  as  it 
will  probably  be  expedient  to  repeat  them  several  times,  it  is  sel- 
dom desirable  to  apply  more  than  six  or  eight  at  once.  The 
warmth  of  the  poultice  is  as  grateful  as  at  the  outset  of  the  aft'ec- 
tion,  while,  if  the  pain  is  very  severe,  the  use  of  laudanum  instead 
of  water  in  mixing  it  will  render  it  a  very  powerful  local  sedative, 
and  its  employment  need  not  .at  all  interfere  with  the  use  of  the 
belladonna  and  mercurial  ointment  of  which  I  spoke  just  now.  I 
am  not,  however,  accustomed,  in  cases  which  have  already  ad- 
vanced to  the  formation  of  a  definite  tumor,  to  rely  exclusively 
on  the  efiects  of  depletion  and  of  general  hygienic  measures,  but 
usually  give  small  doses  of  some  mikt  mercurial  preparation,  and 
continue  their  use  sufficiently  long  to  produce  slight  soreness  of 
the  mouth.  A  five-grain  pill,  composed  of  equal  parts  of  Dover's 
powder  and  gray  powder,  given  twice  a  day,  usually  has  tliis  eficct 
in  a  week  or  ten  days,  and  thus  employed  it  seems  to  have  the 
twofold  result  of  preventing  the  extension  of  mischief  on  the  one 
hand,  and  of  promoting  the  absorption  of  the  products  of  inflam- 
mation on  the  other.  If  the  symptoms  are  urgent,  I  sometimes 
give  the  pill  every  six  hours,  but  am  not  in  the  practice  of  giving 
calomel,  nor  even  of  persevering  witli  the  more  frequent  doses  of 
gray  ])Owder,  if  they  should  appear  to  irritate  the  bowels.  As  in 
most  local  inflammations,  the  night  is  usually  the  time  of  the 
greatest  suffering,  and  an  anodyne  is  generally  needed  towards 
evening;  camphor  in  five-grain  doses  being  a  very  useful  addi- 
tion to  any  opiate  which  may  be  employed. 

It  is  seldom  that  an}'  rigorously  antiphlogistic  plan  is  suitable 
in  this  stage  of  the  aftection.  Good  beef-tea  is  indispensable,  wine 
and  tonics  are  generally  needed  ;  I  think  I  mny  say  always  when 
any  even  vague  sense  of  fluctuation  shows  that  matter  in  some 
considerable  quantity  is  already  present.  A  disposition  to  irrita- 
bility of  the  bowels  frequently  contraindicates  the  use  of  quinine, 
and  I  therefore  generally  prefer  the  liquor  cinchonie,  as  being  free 
from  any  of  those  objections  which  may  be  alleged  against  most 
other  preparations  of  bark. 

Slowly,  almost  inipcrce[)tibly,  in  f>roportion  as  the  symptoms  of 
constitutional  disorder  abate,  the  swelling  itself  in  some  instances 
diminishes  in  size,  till  at  length  an  indistinct  thickening  is  all  that 
is  left  behind.  But  still  this  is  a  more  lavorable  issue  than  we 
often  meet  with,  or  than  we  can  ever  venture  to  count  upon,  where 
a  distinct  tumor  has  formed.     Olten,  though  some  abatement  of 


358  QUESTION    OF    PUNCTURE 

the  general  sj^mptoms  takes  place,  tlie  tumor  enlarges,  becomes 
tenser,  and  feels  more  elastic  ;  a  vague  sense  of  deepseated  fluc- 
tuation is  communicated  to  the  finger,  and  may  continue  for  weeks 
without  growing  more  perceptible,  till  at  length  the  abscess  begins 
to  discharge  itself  through  one  or  other  of  the  channels  which  were 
described  in  the  last  Lecture.  The  question  now  naturally  sug- 
gests itself,  whether,  when  sup[»uration  has  once  occurred,  we 
cannot  expedite  the  escape  of  the  matter,  and  thereby  hasten  the 
recovery  of  the  patient  ?  I  believe  that  as  a  general  rule  it  is  safer 
to  leave  the  emptying  of  the  abscess  entirely  to  nature,  rather  than 
to  attempt  the  evacuation  of  its  contents  by  puncture;  those  cases 
alwaj's  excepted  in  which  the  inflammation  has  attacked  the  cellu- 
lar tissue  external  to  the  peritoneum,  where  the  abscess  conse- 
quentl}'  points  in  the  abdominal  wall.^  In  those  cases  the  very 
tardy  advaiTce  of  the  matter  towards  the  surface  may  sometimes  be 
accelerated  by  the  application  of  a  blister;  for  even  here  it  is  not 
expedient  to  make  an  incision  so  long  as  any  considerable  thick- 
ness of  parts  intervenes.  In  the  far  more  frequent  instances  in 
which  the  seat  of  the  mischief  is  within  the  pelvic  cavity,  the  pus 
tends  to  escape  either  per  vaginam  or  per  rectum,  and  the  attempt 
to  anticipate  by  puncture  the  exact  course  which  it  may  take  is 
very  frequently  unsuccessful,  and  not  always  safe  ;  while  the 
danger  of  the  rupture  of  the  purulent  collection  into  the  peritoneal 
cavity  is  by  no  means  so  done  away  with  by  the  existence  of  a 
counter-opening  as  might  be  supposed ;  and  my  own  observation 
of  the  occurrence  of  this  accident,  where  a  free  communication 
existed  with  the  vagina,  is  far  from  being  a  solitary  case.  The 
natural  relation  of  parts  is  much  changed  by  the  eflfects  of  the  in- 
flammation;  the  swellins:  and  tension  of  the  vaciinal  walls  extend 
far  beyond  the  limits  which  circumscribe  any  actual  collection  of 
matter,  and  it  is  very  likely  that  the  trocar  may  be  merely  thrust 
through  hardened  textures,  and  though  [)assing  very  near  to  the 
collection  of  matter,  may  entirely  fail  to  enter  it.  The  extent  and 
relations  of  the  tumor  can  be  most  accurately  determined,  and 
puncture  can  consequently  be  most  safely  performed,  when  the 
cellular  tissue  between  the  vagina  and  rectum  has  been  tliC  seat  of 
the  inflammation ;  and  a  Pouteau's  trocar  introduced  by  the  vagina 
will  generally  reach  the  matter,  if  the  indications  of  its  presence 
have  been  distinct.     In  one  case,  where  inflammation  of  the  cellu- 

1  There  are  few  points  of  practice  concerning  which  there  is  so  general  an 
agreement  as  this  of  the  inexpediency  of  earlj^  puncture  of  these  collections  of 
matter.  Bernutz,  op.  cit.,  p.  434-6,  accepts  the  jirinciple ;  Aran,  op.  cii.,  p.  740, 
insists  on  it  more  strongly,  and  observes,  "  There  is  no  evidence  of  the  possihility 
of  preventing,  bj-  the  artificial  opening  of  these  purulent  collections,  the  formation 
of  spontaneous  openings  in  other  situations,  and  especially  into  the  peritoneal 
cavity.  There  are,  on  the  contrary,  many  observations  on  record  of  the  occurrence 
of  these  perforations,  sometimes  on  the  very  day,  sometimes  several  days  after  the 
puncture  of  the  abscess."  Becquerel,  Traiie  des  Maladies de  V  Vterua,  8vo.,  Paris, 
1859,  vol  i,  p.  464,  expresses  the  same  opinion  still  more  decidedly,  and  lays  down 
the  rule  that  "  the  abscess  is  never  to  be  opened,  even  though  its  apparent  pointing 
in  one  situation  should  seem  to  invite  interference." 


OF    ABSCESS    CONSIDERED.  359 

lar  tissue  between  the  uterus  and  bladder  had  issued  in  suppura- 
tion, the  escape  of  ten  ounces  of  pus  on  puncture  being  made 
proved  the  expediency  of  the  interference.  In  a  few  days,  how- 
ever, the  vaginal  tumor  had  reacquired  almost  its  former  size  ;  the 
puncture  was  repeated,  but  no  pus  followed,  for  tlie  trocar  had  at 
once  entered  the  bladder  through  the  firm  and  oedematous  vaginal 
wall ;  an  accident  which  fortunately  was  not  followed  by  any  bad 
consequences.  The  previous  introduction  of  a  silver  catheter  into 
the  bladder  in  the  one  case,  and  examination  made  simultaneously 
with  one  finger  in  the  rectum  and  the  other  in  the  vagina  in  the 
other  case,  will  suflUce  to  prevent  a  mistake  which  otherwise  is 
more  easily  committed  than  might  be  supposed  possible. 

The  management  of  the  patient  after  the  discharge  of  the  con- 
tents of  the  abscess  calls  for  no  special  rules.  The  chief  difi'ercnce 
indeed  between  those  cases  in  which  the  discharge  of  pus  takes 
place,  and  those  in  which  it  is  either  not  secreted  or  is  absorbed, 
consists  in  the  greater  degree  of  debility  to  which  in  the  former 
circumstances  the  patient  is  reduced;  a  debility  which  is  often 
extreme  if  the  suppuration  has  been  extensive,  or  if  the  discharge 
of  pus  is  of  long  continuance.  Even  then,  how^ever,  and  in  spite 
of  well-marked  hectic  fever,  and  of  sweats  alternating  with  colli- 
quative diarrhoea,  by  which,  and  by  the  exhaustion  produced  by 
continued  suffering,  life  seems  sometimes  to  be  seriously  threat- 
ened, the  disease  terminated  fatally  only  in  three  out  of  the  fifty- 
nine  patients  on  whom  these  remarks  are  founded. 

With  reference  to  the  thickening  left  behind  after  the  cessation 
of  all  active  inflammation,  I  do  not  think  that  we  can  do  much 
more  than  trust  to  time  for  its  gradual,  often  indeed  for  its  partial 
removal.  Blisters,  indeed,  occasionally  applied  in  the  iliac  region 
do  something  to  relieve  the  pain  and  uncomfortable  sensations 
which  may  long  outlast  the  other  symptoms ;  and  they  may,  per- 
haps, somewhat  accelerate  the  removal  of  thickening  in  the  sub- 
stance of  the  broad  ligament.  I  have  little  faith,  however,  in  the 
external  application  of  iodine,  or  in  its  introduction  as  an  ointment 
into  the  vagina;  nor  do  I  think  that  the  subjecting  a  patient  to  a 
course  of  mercurial  remedies,  or  of  preparations  of  iodine,  is  likely 
to  effect  any  local  good  at  all  equivalent  to  the  impairment  of  the 
constitutional  powers  which  such  remedies  can  scarcely  fail  to 
produce. 

Within  the  past  fifteen  years  attention  has  been  called,  chiefly 
by  French  writers,'  to  cases  in  which  tumors  have  been  formed  by 

'  Cases  of  pelvic  tumor,  giving  issue  not  to  matter  but  to  more  or  loss  altered 
blood,  are  scattered  here  and  there  through  our  medical  records,  and  some  of  them 
may  be  found  referred  toby  M,  Huguier,  in  a  lecture  on  uterine  hiematocele,  which 
he  gave  before  the  Surgical  Society  of  Paris,  on  May  28,  I80I.  As  early  as  1843, 
M.  Velpeau,  at  p.  125  of  his  Rpclic.rdies  siir  les  CavUes  Ctosrs,  gave  an  account  of 
an  instance  in  wliich  he  evacuated  the  sanguineous  contents  of  one  of  these  swell- 
ings, and  afterwards  injected  a  solution  of  iodine  into  its  cavity.  He  seems,  too, 
to  have  entertained  a  correct  idea  as  to  the  nature  of  the  affection  ;  but  the  mistake 
into  which  ]\[.  Malgaigne  fell  in  the  year  18-")0,  wlio,  thinking  to  enucleate  a  iii)rous 
tumor  of  the  posterior  uterine  wall,  opened  one  of  these  collections  of  blood  behind 


360  SOURCE    AND    SEAT    OF    BLEEDING 

the  effusion  of  blood  in  the  immediate  vicinity  of  the  uterus.  The 
name  of  uterine,  retro-uterine,  or  peri-uterine  hoematocele  has  been 
employed  to  designate  these  effusions  which  take  place  usually 
into  the  cul-de-sac  between  the  uterus  and  rectum,  and  are  gener- 
ally consequent  on  some  disorder  of  the  menstrual  function,  often 
on  its  temporary  suppression. 

The  source  and  seat  of  the  hemorrhage  in  these  cases  have  been 
a  subject  of  much  difference  of  opinion,  and  while  some  writers 

the  womb  (an  operation  which  was  followed  bj'  fatal  hemorrhage),  shows  that  the 
subject,  even  down  to  this  time,  had  attracted  very  little  attention. 

In  the  year  1851  M.  Kelaton  gave  some  lectures  on  the  subject  of  uterine,  or,  as 
he  termed  it  from  its  usual  situation,  retro-tiierine  hematocele,  which  were  published 
in  the  Gazette  des  JHopitaux,  Dec.  11  and  13,  1851.  In  them  he  refers  to  15  cases, 
— ^namely,  6  of  his  own,  2  reported  by  Bourdon  as  occurring  in  the  practice  of  M. 
Kecamier,  1  reported  by  M.  Laugier,  in  vol.  v  of  the  Dlctlonnaire  en  30  voluynes,  2 
cases 'which  Nelaton  saw  in  the  practice  of  M.  Beau,  1,  IJalgaigne's  unfortunate 
case,  1  of  M.  Dufraigne,  1  of  M.  Latis,  1  of  M.  Huguier.  He  has  since  recorded 
another  case  in  the  Monifeur  des  HCjniaux,  August  23,  185G,  and  has  made  addi- 
tional remarks  on  the  aflection  in  the  Gazette  des  Ilopitaux,  1855,  No.  23,  in  which 
he  advocates  an  expectant  mode  of  treatment.  Other  cases  are  recorded  by  M. 
Gallard,  Union  Medicale,  1855,  and  Gazette  Hebdomadaire,  Oct.  9, 1857  ;  Laborderie, 
Gazette  des  HOpitaux,  1854,  No.  149  ;  Bernutz,  Arcldves  de  Medecine,  June,  1848,  p. 
188  ;  Piogey,  Bull,  de  la  Societe  Anatotnir/iie,  1850,  p.  91 ;  Kobert,  Bull,  de  la  Soc.iete 
de  Cliiruryie,  May  22,  1851,  p.  136,  and  Gazette  des  Nopitaitx,  ilay  5,  1855,  p.  204; 
Follin,  Gazette  des  JlCpitaux,  1855,  June  5,  p.  200;  Laborderie,  ibid.,  1854,  No.  149; 
Monod,  Bull,  de  la  Societe  de  CIm-itrgie,  June  4,  1851,  p  154;  and  Marotte,  ibid., 
p.  152  ;  and  Engelhard,  Archives  de  Medecine,  June  1857.  There  is  besides  much 
valuable  information  to  be  gathered  from  the  discussion  on  the  subject  which  took 
•place  in  the  Societe  de  Chirvrgie,  May  14,  21,  and  June  4,  1851,  and  which  is  re- 
ported at  pp.  132,  154  and  151  of  the  Bulletin,  and  in  the  inaugural  thesis  of  M. 
Vigufes,  Des  Tumeurs  Sanguines  de  V Excavation  Pelvienne  clitz  la  Feinme,  4to.,  Paris, 
1850,  with  which,  however,  I  am  acquainted  only  through  an  abstract  in  Schmidt's 
JalkTbiichcr.  Besides  these  communications,  all  of  wliicii  are  of  a  directly  practical 
character,  one  of  a  theoretical  kind  was  addressed  bj'  M.  Laugier  to  the  Academic 
des  Sciences,  and  is  published  at  p.  455  of  vol.  xl  of  the  Coniptes  liendus.  Its  object 
is  to  connect  the  occurrence  of  these  effusions  with  the  escape  of  the  ovule  at  or 
about  the  menstrual  period.  These  historical  details  are  rendered  almost  super- 
fluous since'the  publication  of  the  works  of  MM.  Becquerel,  Aran,  and  Nonat,  in 
all  of  which  full  notice  is  taken  of  this  ati'ection.  M-  Voisin,  in  an  expansion  of 
his  inaugural  thesis,  has  published,  under  the  title  i)e  l^HemaiocUe  Retro-Uterine, 
8vo.,  Paris,  18G0,  an  essay  which  embodies  to  a  great  degree  the  opinions  of  M. 
N41aton  ;  and  M.  Bernutz,  whose  claims  to  priority  in  recognition  of  this  affection 
I  cannot,  however,  admit,  has  treated  the  subject  with  his  usual  elaborate  detail  in 
the  first  volume  of  his  work  on  Diseases  of  Women. 

In  Germany  these  effusions  of  blood  have  been  less  carefully  studied  than  in 
France.  Scanzoni's  description  is  avowedly  drawn  from  Fren'ch  sources,  and  he 
expresses  his  opinion  that  the  frequency'  of  the  affection  has  been  much  overesti- 
mated. Some  notice  of  it  is  taken  by  (Jr^d6,  Mo7iatschriftf.  Geburtskunde,  vol.  ix, 
p.  1 ;  Breslau,  ibid.,  p.  455;  Hirtzfelder,  ibid.,  vol.  x,  p.  812;  and  Hegar,  vol.  xvii, 
p.  418,  as  well  as  by  Braun  of  Vienna,  whose  paper,  however,  I  know  only  indi- 
rectly. Virchow,in  his  new  work,  Die  Krankhaflen  GeschwUlsie,  8vo.,  Berlin,  1863, 
has  also  studied  its  morbid  anatomy. 

Dr.  Tilt  is  the  first  English  writer  who  noticed  the  affection,  in  the  second  edi- 
tion of  his  work  on  Diseases  of  Women,  p.  261.  Since  then  it  has  received  due 
attention  in  this  country;  the  lectures  of  Dr.  Simpson,  and  the  treatises  of  Dr. 
McClintock  and  Dr.  Graily  Hewitt,  containing  notices  of  it;  while  the  interesting 
case  published  by  Dr.  Madge,  in  vol.  iii  of  the  Transactions  of  the  Obstetrical  So- 
ciety, and  the  very  valuable  paper  of  Dr.  Matthews  Duncan  in  the  Edinburgh  Medi- 
cal Journal,  Nov.,  1862,  must  not  be  passed  unnoticed,  any  more  than  the  able 
thesis  of  Dr.  Tuckwcll,  of  Oxford,  On  Effusion  of  Blood  in  the  Neighborhood  of  the 
Uterus,  8vo.,  Oxford,  1863. 


IN    UTERINE    HiEMATOCELE.  361 

have  believed  that  the  bleeding  may  take  place  alike  into  the  peri- 
toneal cavity,  or  into  the  cellular  tissue  around  the  uterus,  or  lining 
the  pelvis,  others  are  disposed  to  believe  that  the  blood  invariably 
occupies  the  cavity  of  the  peritoneum.  The  weight  of  evidence 
is  decidedly  in  favor  of  the  latter  view,  which  is  that  taken  by 
Yirchow,  as  well  as  by  Bernutz  and  Aran,  and  I  do  not  know  of 
any  post-mortem  examination  made  with  due  care  in  which  the 
seat  of  the  efiusion  has  been  clearly  proved  to  be  extra-peritoneal. 
The  blood  seems  to  be  poured  out,  in  the  great  majority  of  in- 
stances, either  from  the  rupture  of  the  congested  ovary  itself,  or 
else  from  the  fimbriated  extremity  of  the  Fallopian  tube  of  one  or 
other  side,  whence  it  gravitates  into  the  retro-uterine  pouch,  and 
forms  there  a  distinct  tumor,  which  pushes  the  uterus  forwards 
and  somewhat  upwards.  A  few  cases  are  on  record  where  the 
blood  has  been  thus  poured  out  in  such  quantity  as  to  destroy  the 
patient  almost  at  once ;  and  though  some  of  these  have  been  in- 
stances of  extra-uterine  foetation  and  of  the  rupture  of  the  Fallo- 
pian tube,  yet  this  explanation  does  not  hold  good  of  all ;  and 
suddenly  fatal  bleeding  from  the  uterine  appendages  into  the  peri- 
toneum must  be  admitted  as  a  possible  occurrence  in  the  unim- 
pregnated  condition.  Any  hemorrhage  so  profuse  as  at  once  to 
destroy  life  is  indeed  quite  an  exceptional  occurrence,  and  usually 
the  blood  poured  out  speedily  coagulates.  It  then  excites  inflam- 
mation around  it,  and  becomes  inclosed  within  a  sac  formed  partly 
by  the  adhesion  of  the  coils  of  intestine  to  the  uterine  appendages, 
and  to  each  other,  partly  by  false  membrane.  Within  the  sac  thus 
formed  the  same  changes  now  take  place  as  occur  in  blood  efiused 
elsewhere.  In  the  most  favorable  cases  it  becomes  by  degrees 
absorbed,  in  others  inflammation  is  set  up  (usually  consequent  on 
some  increase  of  local  congestion,  and  fresh  outpouring  of  blood) 
in  the  cyst  wall ;  pus  becomes  intermingled  with  the  blood,  and 
instead  of  absorption  of  its  contents  taking  place,  the  suppurating 
blood-cyst  empties  itself  through  the  rectum,  the  vagina,  or  un- 
happily sometimes  into  the  peritoneal  cavity. 

The  source  of  the  bleeding  in  the  uterine  appendages  themselves 
is  sometimes  verj^  obvious,  as  in  one  instance  where  both  Fallo]»ian 
tubes  were  found  distended  with  blood,  and  a  partially  decolorized 
clot  hanging  from  the  extremity  of  one  of  them.  In  other  cases  a 
distinct  rupture  of  the  ovary  has  been  observed,  and  the  congested 
or  even  apoplectic  condition  of  its  tissue  has  left  no  doubt  as  to 
the  origin  of  the  bleeding.  In  other  instances  again,  where  a 
longer  interval  had  passed  since  the  first  occurrence  of  hemor- 
rhage, its  source  was  not  so  clear;  but  the  grave  alterations  whiidi 
the  uterine  appendages  presented,  or  the  absolute  impossibility 
of  discovering  the  ovary  or  Fallopian  tube  of  one  side,  showed 
plainly  that  in  them  the  evil  had  originated.  Thus,  in  one  case 
where  I  made  the  post-mortem  examination  of  a  patient  in  whom 
for  a  year  symptoms  of  uterine  hematocele  had  existed,  one  ovar}' 
could  not  be  discovered  even  after  the  most  careful  search,  while 
the  other,  in  addition  to  a  serous  cyst  of  the  size  of  a  pullet's  egg, 


362  SYMPTOMS   AXD    COURSE 

presented  an  extravasation  of  blood  into  its  substance  as  large  as 
a  sugared  almond.  The  bleeding  then  takes  place  from  the  ovary 
itself  or  from  the  tube ;  and  now  and  then  perhaps  in  this  latter 
case  from  the  reflux  of  blood  to  whose  outflow  from  the  uterus 
some  impediment  existed,  though  usually  from  the  congested  lining 
of  the  tubes  themselves. 

Blood  poured  out  from  other  sources  may  indeed  collect  in  the 
neighborhood  of  the  uterus,  in  obedience  to  the  mere  laws  of 
gravity,  but  it  would,  I  think,  be  an  error  to  call  such  exceptional 
occurrences  cases  of  uterine  liDematocele.  One  theory  of  the  source 
of  these  hemorrhages  must,  however,  be  noticed,  if  for  no  other 
reason,  at  least  on  account  of  the  reputation  of  its  author.  It  is 
that  of  Yirchow,^  whq  says, — "In  my  opinion  the  blood  in  these 
cases  is  usually  derived  almost  or  altogether  from  the  newly  formed 
vessels  of  false  membranes  produced  by  previous  pelvic  perito- 
nitis." Even  Virchow's  theories  ought  to  have  some  clear  evidence 
to  rest  on.  I  know  of  none  that  would  prove  pelvic  peritonitis  to 
be  an  ordinary  precursor  of  uterine  hivjmatocelc. 

We  learn,  then,  from  these  observations  the  existence  of  a  pre- 
viously unknown  hazard  attendant  on  disorders  of  the  sexual  sys- 
tem in  women ;  that  not  merely  may  intense  congestion  lead  to 
profuse  and  dangerous  floodings,  or  functional  disturbance  issue 
in  inflammation  of  parts  in  the  vicinity  of  the  uterus,  but  also  that 
vessels  may  give  waj-,  and  hemorrhage  take  place  inwardly,  in 
situations  where  it  is  hard  to  discover,  and  still  harder  to  suppress. 
As  might  be  expected,  the  accident  is  one  which  takes  place  only 
during  the  period  of  sexual  vigor,^  it  having  occurred  in  79  women 
at  the  following  ages: 

Under  20  in    4 

Between  20  and  30  "  51 

"       30    "    35  "  17 

"       85    "    40  "     6 

At  40  "     1 

79 

Cases  have  not  at  present  been  recorded  in  suflicient  number  to 
prove  the  comparative  influence  of  marriage  and  childbearing  on 
the  production  of  the  affection.  It  seems,  liowever,  to  stand  but 
rarely  in  any  direct  relation  to  pregnancy  or  miscarriage;  while 
the  fact  that  it  has  sometimes  been  induced  by  sexual  excesses  is 
but  another  illustration  of  the  connection  subsisting"  between  con- 
gestion of  the  pelvic  organs  and  the  outpouring  of  blood  in  the 
neighborhood  of  the  womb.  The  time  of  the  occurrence  of  such 
special  congestion  at  the  return  of  a  menstrual  period  is  allowed 
by  all  writers  to  furnish  the  most  frequent  occasion  for  the  effusion 
of  blood;  and  though  there  is  an  absence  of  unanimity  as  to 
whether  habitual  menorrhagia  or  habitual  dysmenorrhea  most 

1  Die  Krankhaften  Geschwiilsie,  8vo.,  Berlin,  1863,  vol.  i,  p.  152. 

2  See  the  tables  ajipended  to  Dr.  Tuckwell's  thesis. 


OF    UTERINE    H  ^>  M  A  T  0  C  E  L  E.  363 

frequently  precedes  it,  yet  menstrual  irregularity  of  some  kind  or 
other  will  be  found  to  characterize  the  history  of  the  greater  num- 
ber of  patients.  The  liability  to  menstrual  disturbance  in  the  way 
either  of  excess  or  of  defect  indicates  usually  something  wrong 
in  tlie  state  of  the  general  health;  and  just  as  occasional  attacks 
of  menorrliagia  may  occur  in  the  chlorotic  girl,  so  may  the  out- 
pouring of  blood  into  the  peritoneal  cavity  be  in  a  measure  due 
to  constitutional  causes.  The  profuse,  and  sometimes  even  latal 
hemorrhage,  from  the  vulva  or  into  the  peritoneum,  which  has 
been  known  to  occur  in  some  cases  of  purpura  and  of  the  erup- 
tive fevers,  is  but  an  exaggerated  illustration  of  this  fact;  and  my 
own  experience  by  no  means  leads  me  to  the  conclusion  that  the 
women  most  liable  to  these  accidents  are  the  health}''  and  robust.^ 

Be  the  circumstances  in  which  these  hemorrhages  occur  what 
they  may,  there  is  usually  a  certain  family  likeness  among  tlie 
cases  that  will  enable  the  attentive  observer  to  recognize  their 
nature,  or,  at  any  rate,  will  excite  his  suspicions  with  reference 
to  it.  After  some  disorder  of  the  menstrual  function — sometimes 
after  its  temporary  suppression  from  cold,  fatigue,  or  moral  shock 
— severe  abdominal  pain  comes  on,  referred  usually  to  one  or 
other  iliac  region.  It  is  by  no  means  constant  for  the  menses  to 
remain  suppressed  after  the  occurrence  of  this  pain,  which  no 
doubt  marks  the  outpouring  of  blood  into  the  peritoneum;  but 
usually  they  continue,  though  probably  more  scantily  than  in 
health;  while  now  and  then  a  profuse  loss  of  blood  takes  place 
from  the  vagina,  in  spite  of  the  evidence  of  internal  hemorrhage. 
The  pain,  though  severe,  is  seldom  intense,  nor  is  the  shock  which 
accompanies  it  at  all  comparable  to  that  extreme  depression  which 
indicates  the  occurrence  of  intestinal  perforation,  or  the  rupture 
of  the  sac  of  an  extra-uterine  foetation.  I  cannot  say  how  soon 
after  the  shock  and  pain  a  swelling  is  commonly  perceptible  in 
the  abdomen,  nor  what  proportion  is  borne  to  the  other  cases 
by  those  in  w^hich  the  swelling  is  entirely  absent,  though  without 
doubt  the  latter  are  quite  the  minority.  I  have  detected  the  swell- 
ing within  48  hours  after  the  first  symptom,  as  a  vaguely  defined 
hard  lump  in  the  iliac  region,  apparently  of  the  bigness  of  the 
fist,  not  quite  even,  not  movable,  tender  on  pressure,  and  feeling 
so  similar  to  the  swelling  wliich  is  felt  in  cases  of  inflammation 
of  the  uterine  appendages,  that,  apart  from  its  history,  one  would 
be  likely  to  make  a  mistake  as  to  its  real  nature. 

Pain,  exacei'bated  at  uncertain  intervals,  as  is  all  pain  associated 
with  uterine  ailment,  tenderness  limited  to  the  neighborhood  of 
the  ])ainful  part,  and  general  febrile  disturbance,  though  usually 
not  very  severe,  continue  to  be  experienced,  accompanied  with 
difficult  micturition,  with  pain  and  difficulty  in  defecation,  and 
generally  with  an  increased  pain  on  moving  the  leg  of  the  affected 
side,  or  on  attempting  to  assume  the  sitting  posture.  The  febrile 
symptoms  usually  subside  of  their  own  accord,  the  pain  also  dimin- 

1  See  Bernutz,  op.  cit.,  vol.  i,  p.  441-4G0. 


864  SYMPTOMS    AND    COURSE 

ishes,  a  sense  of  weight  in  the  pelvis,  bearing  down,  difEeult  mic- 
turition and  defecation  remaining  behind,  with  difficulty  and  dis- 
comfort in  walking,  and  lead  by  the  discomfort  which  they  occasion 
to  a  vaginal  examination,  and  to  the  discovery  of  the  pelvic  tumor. 

This  pelvic  tumor  difiers  much  in  its  size,  situation,  and  char- 
acter; and  in  some  cases  where  the  symptoms  point  unequivocally 
to  the  existence  of  hsematocele,  no  bulging  of  the  vaginal  wall  has 
been  present.'  For  this  occasional  absence  of  the  pelvic  tumor  I 
do  not  know  how  to  account,  though  I  think  it  is  most  frequent 
when  the  effusion  has  been  extensive.  The  fact  at  any  rate  is  of 
much  importance  to  be  borne  in  mind,  in  order  to  avoid  the  errors 
in  diagnosis  which  we  should  fall  into  if  we  regarded  pelvic  tumor 
as  an  invariable  attendant  on  these  hemorrhages.  Usually,  indeed, 
the  pelvic  tumor  is  present,  and  closely  resembles  that  observed 
in  cases  of  inflammation  of  the  uterine  appendages.  It  is  equally 
firm,  seems  to  be  equally  intimately  connected  with  the  uterus, 
and  has  the  same  globular  form,  differing  perhaps  chiefly  in  this, 
that  it  produces  a  greater  degree  of  displacement  of  the  Avomb 
than  is  observed  in  a  tumor  of  equal  size  due  to  inflammation  in 
the  vicinity  of  the  organ.  This  circumstance  is,  I  think,  readily 
explicable  by  the  rapidity  with  which  blood  is  effused,  as  com- 
pared with  the  greater  slowness  with  which  the  changes  take 
place  that  are  due  to  inflammatory  action,  and  by  which,  more- 
over, the  womb  becomes  fixed  in  its  position,  and  therefore  less 
liable  to  displacement.  The  changes  that  take  place  in  the  tumor 
do  not  seem  to  be  governed  by  any  unvarying  law.  It  often  be- 
comes extremely  firm,  owing  no  doubt  to  the  removal  of  the  more 
fluid  part  of  the  blood,  and  it  is  in  consequence  of  this  change  that 
a  blood-swelling  has  occasionally  been  mistaken  for  a  fibrous 
tumor.  The  supposed  solid  tumor,  however,  will  be  observed,  if 
carefully  watched,  to  diminish  by  degrees,  and  at  length  to  dis- 
appear, leaving  behind  only  a  little  thickening  and  resistance  at 
the  roof  of  the  vagina ;  and  if,  as  is  commonly  the  cnse,  a  swell- 
ing also  existed  in  the  iliac  region,  that,  too,  will  diminish  at  the 
same  rate  with  the  one  felt  per  vaginam,  or  will  even  be  removed 
with  still  greater  rapidity.  In  other  instances,  the  tumor  having 
shrunk  from  the  dimensions  which  it  presented  at  first,  will  once 
more  suddenly  increase,  such  increase  coinciding  with  a  more  or 
less  distinct  menstrual  efltbrt,  often  with  actual  menstruation ;  and 
in  a  doubtful  case  there  is  nothing  more  characteristic  of  its  true 
nature  than  the  sudden  increase  of  the  swelling  coinciding  with  a 
menstrual  period. 

The  gradual  absorption  of  the  blood,  and  the  disappearance  of 
the  tumor  as  the  patient  becomes  convalescent,  is  yet  only  one 
mode,  and  that  by  no  means  the  most  common,  in  which  this 

1  As  in  case  1,  in  Dr.  Duncan's  paper.  I  recollect  two  cases  which  came  under 
my  own  observation,  and  which  I  now  believe  to  have  been  cases  of  uterine  ha^mato- 
cele,  wliere  the  absence  of  any  swelling  in  the  vagina  confused  me,  and  prevented 
my  forming  a  satisfactory  diagnosis.  I  think  that  now,  with  larger  experience,  I 
should  read  them  rightly. 


OF    UTERINE    HiEMATOCELE.  365 

accident  terminates.  Of  eight  cases  of  which  I  have  preserved  a 
record,  there  was  but  one  in  which  the  tumor  was  removed  by  a 
process  of  simple  absorption ;  and  in  this  instance  the  swelling 
was  limited  to  the  right  iliac  region,  and  produced  no  bulging  of 
the  vaginal  wall.  In  two  cases  a  discharge  of  blood,  partly  fluid, 
partly  coagulated,  took  place  from  the  rectum ;  in  a  fourth,  sup- 
puration preceded  its  discharge,  and  blood-stained  pus  escaped  by 
the  rectum  ;  and  in  a  fifth,  the  sac  burst  into  the  peritoneum,  and 
the  patient  died.  In  the  three  remaining  cases  the  tumor  was 
punctured  by  the  vagina;  and  in  the  last  of  them  the  ailment 
was  already  chronic,  and  the  blood-cyst  had  become  an  abscess 
long  before  the  patient  came  under  my  care. 

It  may  be  worth  while  to  narrate  briefly  the  particulars  of  these 
cases,  since  in  the  various  circumstances  in  wdiich  they  supervened, 
and  in  the  varying  courses  they  ran,  they  may  serve  to  illustrate 
more  completely  the  history  of  this  affection.  In  all  the  cases  but 
one  the  patients  were  married  women,  of  whom  three  were  sterile; 
four  had  given  birth  to  children.  This  exceptional  case  was  that 
of  a  young  unmarried  woman,  aged  twenty-two,  who,  having  long 
suflered  from  attacks  of  pain  of  a  paroxysmal  character  in  the  left 
iliac  region,  was  surprised  at  the  age  of  nineteen  by  a  profuse 
discharge  of  a  dirty  reddish-brown  color  from  the  vagina,  which 
continued  in  varying  quantity  for  many  weeks,  and  was  then  suc- 
ceeded by  a  puriform  discharge,  occurring  in  gushes,  which  con- 
tinued down  to  the  time  of  her  coming  under  my  care.  A  tumor 
in  the  iliac  region,  and  another  felt  behind  the  uterus,  fixing  that 
organ  in  its  place,  were  the  evidences  of  some  bygone  inflamma- 
tion— of  an  old  pelvic  abscess,  in  short,  the  origin  of  wdiich  in  an 
effusion  of  blood  was  rather  inferred  from  the  patient's  previous 
historj'  than  actuall}-  demonstrated.  Puncture  of  the  abscess,  and 
the  injection  of  a  solution  of  iodine  into  its  cavity,  were  followed 
by  its  complete  cure,  and  the  patient  afterwards  married,  though 
she  never  became  pregnant.  The  second  case  was  likewise  one 
in  ■svhieh  the  evil  terminated  in  suppuration;  but  the  symptoms 
ran  a  more  acute  course,  and  there  was  no  re-collection  of  the 
matter  after  its  spontaneous  discharge  by  the  bowel.  The  patient 
was  a  woman  aged  thirty-four,  who,  though  married  for  fourteeu 
years,  had  never  become  pregnant.  For  two  years  she  had  habit- 
ually menstruated  profusely,  and  for  two  months  the  discharge 
had  been  actually  menorrhagic.  On  the  return  of  the  third  period, 
however,  the  loss  was  extremely  scanty;  she  experienced  severe 
pain  in  the  back  and  legs,  with  tenderness  and  some  difficulty  in 
micturition.  Scanty  menstruation  had  still  been  going  on  for 
some  days  when  the  patient  came  under  my  care.  There  was 
then  a  distinct  swellina;  in  the  left  iliac  res-ion,  with  much  thick- 
ening  in  the  recto-vaginal  pouch.  In  the  course  of  fourteen  days 
this  thickening  and  fulness  assumed  the  characters  of  a  definite 
tumor,  which  increased  in  size,  until  at  the  end  of  six  weeks  it 
burst,  and  discharged  per  rectum  a  discolored  pus,  and  a  fortnight 
after  the  patient  left  the  hospital  well.     The  patient's  previous 


366  CASES    ILLUSTRATIVE    OF    COURSE 

history,  the  character  of  her  symptoms,  and  the  discolored  pus 
which  escaped  from  the  howel,  suffice,  I  think,  to  point  to  the 
origin  of  this  pelvic  abscess  in  a  previous  sanguineous  effusion 
around  the  uterus.  The  third  patient  I  saw  but  once,  though  I 
heard  of  her  subsequent  history;  and  I  refer  to  it  here  because  it 
illustrates  the  most  favorable  course  which  may  be  taken  by  these 
cases  in  their  less  severe  forms.  A  lad}^  who  was  between  twenty 
and  thirty  years  old,  and  had  given  birth  to  several  cliildren, 
caught  cold  during  a  menstrual  period,  and  the  discharge,  though 
not  suppressed,  was  immediately  much  lessened  in  quantity. 
Simultaneously  with  this  diminution  of  the  menstrual  flow,  she  ex- 
perienced considerable  abdominal  pain,  aggravated  in  paroxysms; 
and  at  the  end  of  three  days  a  distinct  swelling  was  discovered  in 
her  right  iliac  region.  This  swelling,  when  I  saw  the  patient 
about  lour  days  from  the  commencement  of  her  illness,  was  above, 
but  in  the  direction  of  Poupart's  ligament,  of  about  the  size  of  the 
fist,  but  of  a  more  elongated  form,  not  movable,  tender,  but  not 
intensely  so  to  the  touch;  and  it  was  unassociated  with  uterine 
displacement,  or  with  more  than  a  vague  sense  of  fulness  at  the 
roof  of  the  vagina.  Absolute  rest,  and  an  expectant  plan  of  treat- 
ment, were  followed  b}'  the  complete  disappearance  of  the  swelling, 
and  by  the  patient's  restoration  to  perfect  health.  The  fourth 
case  is  of  special  interest,  on  account  of  the  development  of  the 
symptoms  out  of  the  sequelte  of  an  abortion,  not  out  of  the  dis- 
turbance of  a  menstrual  period.  The  patient,  aged  thirty-three, 
having  miscarried  at  the  sixth  week,  followed  her  occupation  as 
a  washerwoman  without  paying  any  attention  to  her  condition, 
and  this  exertion  was  followed  by  great  increase  of  the  sanguineous 
discharge,  which  continued  for  twelve  weeks.  At  the  end  of  this 
time  a  vaginal  examination  detected  a  tumor  behind  the  uterus, 
of  the  size  of  an-  apple.  On  being  punctured  it  gave  issue  to  a 
reddish-brown  discharge,  the  continuance  of  which  for  three  weeks 
was  followed  by  the  complete  disappearance  of  the  swelling.  In 
the  fifth  patient,  aged  twenty-four,  who  for  five  years  had  lived  in 
sterile  marriage,  the  symptoms  gradually  developed  themselves 
during  the  persistence  for  two  months  of  a  discharge  su[)posed  to 
be  menstrual.  Here,  too,  a  tumor  behind  the  womb  gave  issue 
when  punctured  to  a  black  ofiensive  discharge,  which  evidently 
consisted  of  decomposedblood ;  and  the  patient,  having  surmounted 
'an  attack  of  peritonitis,  perfectly  recovered.  The  sixth  case  so 
well  illustrates  the  symptoms  and  the  dangers  of  the  affection, 
that  it  seems  to  me  deserving  of  relation  somewhat  in  detail. 

A  tall,  stout,  and  tolerably  healthy-looking  woman,  twenty-five 
years  old,  who  had  been  married  for  seven  years,  had  been  preg- 
nant four  times,  and  had  given  birth  to  three  living  children,  of 
whom  the  youngest  was  twelve  months  old,  was  admitted  into  St. 
Bartholomew's  Hospital  on  February  22d,  1851.  Her  general 
health  had  been  good,  her  labors  had  been  natural,  and  after  all  of 
them  she  had  menstruated  regularly  during  the  whole  period  of 
lactation.     After  her  third  labor  matters  went  on  as  usual  until 


OF    UTERINE    II  HEMATOCELE.  367 

Christmas,  when  she  menstruated  naturally,  but  ever  since  that 
time  a  sanguineous  discharge,  neither  verjprofusc  nor  intermingled 
with  coagula,  had  been  constantly  present.  For  a  month  she  liad 
pain  of  a  bearing-down  character,  aggravated  by  exertion,  but  not 
notably  relieved  by  rest,  nor  by  any  particular  position;  and  she 
had  also  for  the  same  time  suiicred  from  occasional  fainting  fits. 
Micturition  was  frequent  and  })ainful,  and  her  urine  was  reported 
to  be  both  scantj'  and  high-colored.  A  medical  man  whom  she 
had  consulted  told  her  that  "her  womb  was  down." 

The  abdomen  was  large  and  somewhat  tense,  its  enlargement 
being  due  to  the  presence  of  a  tumor,  the  surface  of  which  was 
slightly  uneven,  occupying  the  whole  of  the  left  side,  extending 
three  inches  above  the  umbilicus,  reaching  about  two  inches  across 
the  mesial  line,  though  gradually  sloping  downwards,  so  that  on 
the  right  side  its  upper  margin  was  an  inch  and  a  half  below  the 
umbilicus.  The  tumor  was  firm,  non-fiuctuating,  very  tender  to 
the  touch,  especially  in  the  left  iliac  region. 

The  finger  on  being  introduced  into  the  vagina  came  almost 
immediately  on  a  somewhat  firm,  elastic  tumor,  of  an  oval  shape, 
of  about  the  thickness  of  the  wrist,  and  which  had  pushed  before 
it  the  posterior  vaginal  wall.  This  tumor  seemed  to  pass  over 
into  the  substance  of  the  uterus  about  half  an  inch  behind  its 
orifice,  the  wdiole  organ  being  so  misplaced  that  the  os  uteri  was 
felt  lying  horizontally  immediately  behind  the  symphysis  pubis. 
The  finger  passed  up  in  the  front  and  right  side  of  the  pelvis 
without  encountering  any  resistance ;  but  at  the  left  side  and 
posterior  part  of  the  pelvis  a  firm  tumor  was  felt  apparently  con- 
tinuous with  that  immediately  behind  the  uterus.  The  vessels  of 
the  tumor  pulsated  very  forcibly. 

About  three  ounces  of  a  bloody  fluid  were  drawn  off  on  the 
tumor  being  punctured  with  a  grooved  needle  through  tlie  vagina. 
Tiie  microscope  discovered  nothing  but  blood  corpuscles  in  the 
fluid,  and  with  the  view  of  emptying  the  tumor  if  possible,  and 
of  thereby  relieving  the  painful  pressure  on  the  rectum,  which 
occasioned  much  distress,  a  Pouteau's  trocar  and  canula  were  in- 
trodnced,  but  only  about  four  ounces  of  fluid  of  the  same  character 
as  before  were  let  out.  The  tumor  w^as  not  thereby  much  dimin- 
islied  in  size,  nor  was  the  patient's  discomfort  much  alleviated. 
On  February  27th  no  fresh  interference  having  been  resorted  to, 
she  was  seized  with  peritonitis,  during  the  course  of  which  there 
was  manifest  increase  of  the  tumor,  which  extended  more  towards 
the  right  side  of  her  abdomen.  By  the  3d  of  ^Nlarch  all  active 
symptoms  were  sul)dued,  and  on  that  day  the  patient  passed  two 
copious  evacuations,  which  were  perfectly  black,  and  appai-ently 
consisted  entirely  of  altered  blood.  The  same  afternoon,  too,  she 
experienced  a  sensation  as  of  something  giving  away  internally, 
and  this  was  immediately  followed  by  an  abundant  gush  Ironi  the 
vagina  of  very  fetid  fluid,  resembling  coflee-grounds  in  appear- 
ance. This  fluid  flowed  at  first  very  abundantly,  afterwards  more 
scantily  till  morning,  when  it  ceased,  though  another  gush  of  it 


368  CASES    ILLUSTRATIVE    OF    COURSE 

took  place  on  the  following  day.  and  afterwards  recurred  occasion- 
ally for  several  days,  acquiring  by  degrees  a  lighter  color,  and  be- 
ing at  last  a  dirty  sero-purulent  matter.  Very  slowly  the  patient's 
general  health  improved,  while  at  the  same  time  her  abdomen 
diminished  in  size,  and  having  measured  forty-six  inches  on  her 
admission,  had  shrunk  to  forty  inches  on  March  24th.  The  tumor 
in  the  left  hypogastric  region  at  the  same  time  manifestly  dimin- 
ished in  size  and  became  more  mesial  in  its  position  ;  and  on  April 
5th  the  uterus  had  nearly  regained  its  natural  situation ;  there  was 
no  longer  any  distinct  tumor  behind  it,  but  a  hard,  scmicartilagi- 
nous  thickening,  ill-defined  as  to  its  extent  and  relations.  On 
April  17th  all  discharge  from  the  vagina  finally  ceased,  and  on 
May  5th  all  trace  of  abdominal  tumor  had  completely  disappeared, 
the  position  of  the  uterus  was  quite  natural,  the  thickening  behind 
it  was  much  lessened.  A  year  afterwards  I  again  saw  the  woman ; 
she  was  in  perfect  health,  menstruating  regularly ;  there  was  no 
trace  of*  abdominal  tumor,  the  uterus  was  perfectly  movable,  and 
there  was  scarcely  any  thickening  to  be  felt  behind  it,  or  to  its 
left  side. 

The  seventh  case  is  important,  as  well  on  other  accounts  as 
because  the  extreme  firmness  of  the  vaginal  swelling  raised  the 
suspicion,  more  than  once  during  the  patient's  illness,  that  it  was 
due  to  a  fibrous  tumor  connected  with  the  posterior  wall  of  the 
uterus.  The  patient  was  twenty  six  years  old,  and  had  given 
birth  to  three  children  during  seven  years  of  married  life.  Four 
months  before  she  came  under  my  notice  she  was  attacked  during 
a  menstrual  period  by  pain  in  the  abdomen  accompanied  by  expul- 
sive eftbrts  of  such  severity  that  her  medical  attendant  thought 
her  about  to  miscarry.  The  pain  by  degrees  subsided,  and  the 
menstrual  flow  was  neither  increased  nor  lessened ;  and  the  two 
succeeding  periods  were  punctual  in  their  return,  though  accom- 
panied by  an  unusual  amount  of  pain.  Her  third  period  was  post- 
poned for  nearly  three  weeks,  and  for  tvro  days  before  the  dis- 
charge appeared  the  patient  suftered  pain  similar  to  that  which 
she  had  before  experienced,  but  more  severe.  The  menses  were 
on  this  occasion  unusually  scanty.  Their  flow  was  accompanied 
by  an  increase  of  pain,  by  sickness,  and  by  so  much  difliculty  in 
micturition,  that  it  was  necessary  on  more  than  one  occasion,  to 
have  the  catheter  passed ;  and  defecation  also  was  attended  by 
an  increase  of  suffering.  It  was  on  the  sixth  day  from  the  com- 
mencement of  these  symptoms  that  the  patient  came  under  my 
notice.  The  uterus  was  then  carried  forwards  and  to  the  right 
side  by  a  swelling  which  occupied  two-thirds  of  the  posterior  and 
left  side  of  the  pelvic  cavity.  The  tumor  was  firm  but  elastic ;  its 
surface  was  smooth,  its  vessels  did  not  pulsate,  and  there  was  no 
increased  heat  of  the  vagina.  It  was  not  until  a  week  later  that 
an  abdominal  swelling  was  detected,  though  it  had  been  previ- 
ousl}'  sought  for ;  but  possibly  the  intense  abdominal  tenderness 
interfered  with  that  minute  examination  which  was  practicable  so 
soon  as  it  had  subsided.     This  swelling  was  situated  in  the  left 


OF    UTERINE    HJEMATOCELE.  369 

iliac  region  ;  it  reached  for  about  three  fingers'  breadth  above 
Poupart's  ligament,  and  from  the  pubis  to  the  iliac  spine;  but  its 
outline  was  indistinct.  For  the  next  fourteen  days  this  abdomi- 
nal swelling  increased  to  nearly  double  its  former  size,  and  at  the 
same  time  its  upper  border  became  much  more  distinct,  but  no 
change  took  place  in  the  pelvic  tumor  other  than  that  the  elas- 
ticity which  at  first  it  had  so  distinctly  presented  became  much 
less  marked.  Without  any  discharge  having  taken  place,  the 
abdominal  tumor  now  began  to  lessen  ;  the  uterine  lips  and  cer- 
vix, which,  on  the  patient's  admission  into  the  hospital,  were  full 
and  pufty,  lost  these  characters  completely,  while  the  hardness  of 
the  tumor  gave  it  a  most  deceptive  resemblance  to  a  fibrous  tumor. 
A  week  afterwards,  exactly  thirty  days  from  the  patient's  admis- 
sion into  the  hospital,  and  thirty-six  from  the  commencement  of 
the  attack,  a  discharge  of  blood  took  place  from  the  rectum,  partly 
fluid,  partly  in  clots  ;  and  this  recurred  more  than  once.  The  ab- 
dominal tumor  was  found  three  days  afterwards  to  have  much 
diminished,  and  that  in  the  pelvis  to  have  altogether  disappeared, 
the  uterus  having  nearly  resumed  its  natural  position.  Fourteen 
days  later  the  patient  left  the  hospital,  a  vague  induration  about 
Poupart's  ligament  indicating  the  former  seat  of  the  abdominal 
tumor,  and  a  little  thickening  about  the  roof  of  the  vagina  and  in 
the  course  of  the  broad  ligament,  interfering  somewhat  with  the 
free  mobility  of  the  uterus. 

The  eighth  and  last  case  was  one  which  I  saw  at  intervals  only 
with  Dr.  Kirby,  of  Gordon  Square,  to  whom  I  am  indebted  for 
many  particulars  of  her  history.  The  patient  was  a  lady  thirty- 
two  years  old,  who  had  been  married  nine  years,  had  given  birth 
to  one  child  between  seven  and  eight  years  before  I  saw  her,  but 
had  never  afterwards  been  pregnant.  Her  labor  was  followed  for 
some  time  by  irregular  and  excessive  menstruation,  which  was  at 
lengtli  suddenly  checked  by  treatment.  For  several  years  after- 
wards menstruation  became  scanty,  postponing,  often  absent  alto- 
gether, and  always  associated  with  niucli  pain  and  sickness.  Kot 
infrequently,  too,  the  constitutional  disorder  continued  unaccom- 
panied by  menstruation,  and  at  last  relieved  by  vomiting  of  blood. 
Gradually  the  more  urgent  symptoms  subsided,  but  lor  some  two 
or  three  years  before  the  commencement  of  her  fatal  illness,  she 
had  much  dysmenorrhooa,  ovarian  tenderness,  and  uterine  i)ain, 
though  there  was  no  change  discoverable  on  a  vagiiud  examina-' 
tion.  On  October  19,  18t)2,  a  menstrual  period  came  on  which 
was  very  abundant  and  protracted,  the  discharge  being  intermin- 
gled with  small  coagula  and  matter  like  dysmenorrh<i'al  mem- 
brane. On  the  return  of  the  next  menstrual  epoch,  though  dis- 
cliarge  had  not  commenced,  the  patient  suddenly  comjilained  of 
a  sense  of  fulness  and  bearing  down,  of  faintness,  and  of  inability 
to  empty  the  bladder,  and  a  tumor  was  now  discovered  in  the 
right  iliac  and  hypogastric  region,  and  the  uterus  was  cari-ied  for- 
wards by  a  swelling  seated  between  it  and  the  rectum.  Poth 
these  tumors  continued,  varying  indeed  in  size,  and  in  thetcnder- 

24 


370  FATAL     CASE    OF    UTERINE     HEMATOCELE. 

ness  of  which  they  were  the  seat,  and  the  abdominal  tumor  was 
sometimes  difficultly  distinguished,  though  that  felt  per  vaginam 
underwent  much  less  considerable  alteration.  The  patient  suf- 
fered from  frequent  and  severe  attacks  of  paroxysmal  pain,  and 
this  pain  always  accompanied  menstruation,  the  periods  of  which 
were  tolerably  regular.  Pain  in  the  tumor,  too,  interfered  with 
any  attempt  at  moving,  and  sleep  was  seldom  obtained  without 
the  use  of  opiates.  In  April,  18()3,  about  five  months  after  the 
commencement  of  her  illness,  the  patient  began  to  have  frequent 
attacks  of  shivering,  with  rapid  pulse,  night  sweats,  and  other 
hectic  symptoms,  under  which  her  health  failed,  though  very 
gradually,  and  temporary  improvement  took  place  now  and  then. 

The  swelling  in  the  abdomen  did  not  notably  increase,  but  re- 
mained about  half  the  size  which  it  had  first  presented,  while  the 
internal  tumor  underwent  no  alteration,  and  thoui>;h  not  absolutelv 
solid,  3'et  yielded  nowhere  any  sense  of  fluctuation. 

It  was  at  length  determined,  after  the  la})se  of  eight  months, 
that  an  exploratory  puncture  should  be  made  with  a  fine  trocar, 
and  that  this  should  be  enlarged  if,  as  there  seemed  no  reason  for 
doubting,  the  collection  of  blood  or  matter  were  reached.  This 
was  accordingly  done  by  Mr.  Paget;  but  though  to  his  own  sen- 
sation as  well  as  to  the  bystanders,  the  trocar  seemed  to  have 
entered  a  cavity,  nothing  flowed  but  a  drop  of  blood.  A  good 
deal  of  constitutional  disturbance,  much  sickness,  some  abdominal 
tenderness,  but  no  severe  pain,  succeeded  this  puncture,  which 
was  made  on  July  11th.  The  patient's  pulse,  too,  became  very 
frequent,  and  her  condition  altogether,  though  not  such  as  to  in- 
dicate immediate  danger,  excited  much  anxiety,  as  it  seemed  to 
point  to  the  existence  of  cyst  inflammation.  In  the  morning  of 
July  20th,  the  above-named  symptoms  having  lasted  without 
marked  aggravation,  the  patient  made  an  attempt  to  void  urine, 
but  finding  herself  unable  to  empty  her  bladder,  sent  for  Dr. 
Kirl)y,  who  found  her  in  a  state  ot  collapse,  and  she  died  at  four 
p.M  on  the  same  afternoon,  haVing  manifested  all  those  symptoms 
which  usually  follow  the  perforation  of  any  important  viscus. 

The  abdomen  was  found  to  contain  a  turbid,  brownish  fluid,  a 
mixture  of  thin  pus  and  blood,  which  had  issued  from  the  pelvic 
cavit}'  and  flowed  among  the  intestines.  There  was  a  general 
fulness  of  vessels  of  both  surfiices  of  the  peritoneum,  and  of  the 
surface  of  the  intestines,  and  a  little  lymph  thinly  deposited  here 
and  there,  evidently  of  comparatively  recent  formation.  Besides 
this,  below  the  umbilicus,  and  especially  in  the  left  iliac  region, 
there  was  a  good  deal  of  roughening  of  the  peritoneum  as  if  from 
old  peritonitis,  and  there  were  many  small  blackened  spots,  old 
ecehymoses,  on  the  roughened  surface.  The  pelvic  contents  were 
bounded  above  by  a  coil  of  intestines  which  was  adherent  to  the 
upper  surface  of  the  pelvic  viscera,  and  thus  formed  a  kind  of 
ej'st  or  sac,  in  the  left  side  of  which  there  was  a  small  triangular 
rent  about  half  an  inch  in  length,  through  which  its  contents  had 
escaped  into  the  abdomen.     This  sac,  which  was  bounded  by  the 


DIAGNOSIS    OF    THE    AFFECTIOX.  371 

left  side  of  the  uterns,  still  contained  about  eight  ounces  of  brown 
pus,  such  as  was  found  in  the  abdomen.  The  reason  of  its  non- 
escape  on  the  puncture  being  made  ])er  vagiuam  was  discovered 
in  the  presence  of  a  layer  of  extremely  firm  black  clot  an  eighth 
of  an  inch  in  thickness,  wliich  lined  the  lower  half  of  the  sac,  and 
was  almost  as  firm  as  a  piece  of  leather,  so  that  the  point  of  the 
trocar  had  failed  to  penetrate  it,  but  had  detached  it  from  the 
walls  of  the  cavity,  and  thus  failed  to  evacuate  its  contents. 

The  right  ovary  contained  a  cyst  the  size  of  a  pullet's  egg,  and 
also  a  large  recent  clot  the  size  of  a  sugared  almond.  No  com- 
munication could  be  made  out  between  either  tube  and  the  sac; 
but  the  left  ovary,  after  the  most  careful  search,  could  not  be  made 
out  among  the  folds  of  the  thickened  and  altered  broad  ligament. 
The  jielvic  tumor  had  completely  disapi)eared  after  death. 

This  case  calls  for  but  little  comment,  though  it  illustrates  ex- 
tremely well  some  of  the  more  characteristic  features  of  uterine 
luematocele.  The  disturbed  menstruation,  the  pain  in  the  per- 
formance of  the  function,  the  appearance  of  the  pelvic  tumor,  the 
firmness  which,  but  for  the  knowledge  one  had  of  the  state  of  the 
womb  before  any  such  swelling  existed,  would  have  raised  the 
question,  whether  by  possibility  it  could  be  a  fibrous  growth,  are 
all  phenomena  with  which  our  previous  study  of  the  subject  has 
made  us  acquainted.  Next  come  the  discovery  of  the  swelling 
in  the  iliac  region,  always  tender,  often  the  seat  of  acute  pain, 
aggravated  in  paroxysms,  and  increased  specially  at  the  menstrual 
periods,  the  cause  of  which  pain  is  partly  explained  by  the  evi- 
dences of  old  pelvic  peritonitis.  Next  may  l)e  added  the  variations 
in  the  size  of  both  the  internal  and  external  swelling,  coincident, 
no  doubt,  with  the  occurrence  of  fresh  eflusion  of  blood,  or  with 
its  partial  absorption,  and  the  diiferent  sensations  of  firmness  and 
elasticity  wliich  the  internal  swelling  communicated  at  different 
times  to  the  finger.  Lastly,  we  have  the  occasional  rigors,  the  ill- 
nuirked  hectic,  the  fitful  advances  towards  convalescence  which 
seemed  as  if  it  were  about  to  be  arrived  at,  but  was  never  actually 
reached;  and  then  the  surgical  interference,  which  sufiiced,  though 
so  slight,  to  call  the  slumbering  mischief  into  activity,  and  to  dis- 
pose the  frail  wall  of  adventitious  membrane  to  give  wa}',  which 
at  length  it  did  under  the  slight  efibrt  made  in  the  attempt  to 
empty  the  bladder. 

There  are  yevcral  conditions  with  which  this  uterine  ha'inatocele 
may  be  confuunchd,  viz.,  extra-uterine  pregnancy,  retroversion  of 
the  [iregmint  uterus,  inllammation  of  the  cellular  tissue  between 
the  uterus  and  rectum,  and  fibrous  or  ovarian  tumor;  and  the 
points  of  similarity  between  each  of  these  are  quite  sufficient  to 
lead  very  readily  into  error.  The  su[ipression  of  the  menses,  the 
abdominal  or  [telvic  discomfort,  and  the  sense  of  l)earing  down 
backwards,  are  symptoms  common  to  efiusion  of  blood  behind 
the  uterus,  and  to  an  extra-uterine  fcetation  between  the  second 
and  fourth  months;  while  the  general  contour  of  the  tumor  is 
very  similar  in  the  two  cases,  and  there  is  often  the  same  remark- 


372  DIAGNOSIS    OF 

able  pulsation  of  the  vessels  distributed  to  it  in  both,  though,  I 
believe,  this  is  by  no  means  so  constant  in  the  case  of  uterine 
haematocele.  The  attacks  of  pain  in  extra-uterine  foetation  are, 
however,  usually  more  intense  and  more  paroxysmal,  while  the 
discomfort  in  the  intervals  is  less ;  the  sanguineous  discharge  is 
absent,  and  the  uterus,  if  examined  with  the  sound,  is  ascertained 
to  be  increased  in  size  ;^  and  even  without  it  the  condition  of  the 
OS  uteri  and  portio  vaginalis  of  the  cervix,  with  the  pufty  lips,  the 
closed  orifice,  and  the  swollen  tissue,  differs  widely  from  the  com- 
pletely undeveloped  state  of  those  parts  in  cases  of  hemorrhage 
about  the  woml). 

The  efl:usion,  when  considerable,  mn}-  cause,  as  it  did  in  the  case 
which  I  have  related,  complete  retroversion  of  the  womb,  a  con- 
dition which,  when  associated  as  it  is  sometimes  with  sup{)ression 
of  the  menses  for  two  or  three  months,  may  raise  the  suspicion  of 
pregnancy,  and  lead  to  the  tumor  being  taken  for  the  fundus  of 
the  enlarged  and  mis})laced  uterus.  I'rofessor  Credd,  of  Berlin, 
relates  an  instance  in  which  these  very  circumstances  led  him  for 
a  moment  into  error,  and  in  which  he  endeavored  vainly  to  re- 
place what  he  su[)posed  to  be  the  pregnant  and  retroverted  womb. 
Further  observation  soon  led  him  right,  and  the  same  considera- 
tions as  rectified  his  diagnosis  may  keep  us  from  error.  The 
cervix  and  os  uteri  i)rosented  none  of  the  changes  of  pregnancy; 
the  bladder  was  not  affected;  and  the  uterine  sound,  which  entered 
readily  in  the  natural  direction,  could  not  be  turned  round  with 
its  concavity  backwards,  nor  be  made  to  enter  the  tumor,  inti- 
mately though  it  seemed  connected  with  the  womb. 

The  characters  of  the  tumor  in  cases  of  inflammation  of  the 
uterine  cellular  tissue  very  closely  resemble  those  of  uterine 
hfematocele,  and  the  history  and  symptoms  present  a  very  near 
analogy  in  the  two  affections.  There  are,  however,  some  points 
of  difference  between  them  which  are  generall}''  sufficiently 
marked  to  preserve  the  attentive  observer  from  error.  Pelvic 
abscess  is  very  generall}'  the  consequence  of  delivery  or  of  abor- 
tion, while  it  is  scarcely  ever  associated  with  any  other  form  of 
menstrual  disorder  than  its  sudden  suppression  ;  the  inflammatory 
symptoms  developing  themselves  directly  out  of  that  accident. 
Uterine  haematocele,  on  the  contrary,  is  seldom  the  immediate  con- 
sequence of  a  single  suppression  of  menstruation  ;  it  is  not  infre- 
quently preceded  by  nienorrhagia,  and  is  often  accompanied,  at 
any  rate  for  a  time,  by  a  copious  sanguineous  discharge,  a  symp- 
tom which  never  attends  u^ton  inflammation  of  the  cellular  tissue 
in  the  vicinity  of  the  uterus.  1  am  not  sure  that  the  consistence 
of  the  tumors  furnishes  any  very  trustwortliy  clue  to  a  correct 
diagnosis,  since  the  degree  of  firmness  of  a  uterine  hsematocele  is 

1  With  reference  to  the  inference  to  be  drawn  from  measurement  of  the  uterine^ 
cavity,  Dr.  Matthews  Duncan  gives  the  important  caution  that  "the  uterus  was 
found  greatly  elongated  in  every  one  of  the  instances  he  had  recorded,  when  the 
hematocele  was  large,  and  in  all  it  contracted  with  the  contraction  of  the  blood- 
sac." 


UTERINE    n.^MATOCELE.  373 

liable  to  very  wide  variations,  but  considerable  value  may  be  at- 
tached to  the  circumstance  that  at  no  period  are  there  the  same 
thickening  and  induration  about  it  which  are  so  remarkable  in 
that  part  of  the  vaginal  wall  adjacent  to  any  collection  of  matter. 

Ovarian  cysts  may  occupy  when  small  the  same  situation  as 
uterine  hsematocele;  the}-  are  not,  however,  so  sudden  in  their 
occurrence,  nor  so  rapid  in  their  increase;  while,  though  their 
development  is  often  associated  with  menstrual  irregularity,  they 
are  not  attended  ]Dy  any  constant  sanguineous  discharge.  The 
ovarian  tumors,  too,  do  not  descend  equally  low  into  the  recto- 
vaginal pouch,  and  consequently  do  not  produce  the  same  difficulty 
in  "defecation,  while,  further,  they  are  not  so  intimately  connected 
with  the  uterine  wall,  and  the  womb  can  usually  by  means  of  the 
sound  be  completely  isolated  from  the  adjacent  swelling. 

Though  this  be  true,  however,  it  must  yet  be  borne  in  mind  that 
the  existence  of  an  ovarian  tumor  is  sometimes  suddenly  dis- 
covered, owing  to  some  special  inconvenience,  pain,  or  unusual 
menstrual  disturbance  which  it  may  have  occasioned  ;  further, 
that  the  two  conditions  may  coexist;  and,  lastly,  that  bulging  of 
the  recto-vaginal  wall  in  cases  of  hematocele,  although  usually 
very  marked,  is  sometimes  altogether  absent,  and  this  even 
though  the  collection  of  blood  may  be  very  extensive,  and  the 
abdominal  tumor  may  have  attained  a  very  considerable  size.  In 
the  tirst  case  related  by  Dr.  Duncan,  though  the  tumor  reached  as 
high  as  the  umbilicus,  so  that  its  contents  were  let  out  by  puncture 
of  the  abdominal  walls,  yet  the  evidence  of  the  collection  of  bloody 
fluid  not  having  been  contained  within  an  ovarian  cyst  appears  to 
me,  as  it  does  also  to  him,  decidedly  to  preponderate.  Many  in- 
stances of  the  same  kind,  too,  are  on  record,  and  one  came  under 
my  own  notice  (though  I  have  not  included  it  among  those  on 
which  my  observations  are  founded),  in  which  the  very  large  size 
attained  by  the  abdominal  tumor,  coupled  with  the  absence  of  any 
bulging  of  it  into  the  vagina,  led  me  to  regard  the  swelling  as 
ovarian,  though  I  have  since  entertained  grave  doubts  as  to  the 
correctness  of  this  opinion. 

In  the  great  majority  of  instances  the  distinction  between  a 
fibrous  tumor  and  an  effusion  of  blood  will  be  attended  by  little 
difficulty,  though  we  know  that  very  able  men  have  sometimes 
mistaken  the  one  for  the  other.  It  must  not  be  forgotten  that  the 
liistory  one  receives  of  a  patient's  illness  is  too  often  imperfect, 
exaggerated,  or  even  in  many  respects  altogether  incorrect.  In  the 
next  place,  the  presence  of  a  tumor  in  the  iliac  region  by  no  means 
clears  up  the  difficult/ as  to  the  nature  of  that  felt  per  vaginam, 
since  both  may  be  fibrous  growths,  or  both  may  be  due  t<^  the 
effusion  of  l)lood,  while  pain  and  menstrual  irregularity  may  attend 
on  either  affection,  and  the  degree  of  firmness  of  the  swelling  is  a 
most  inadequate  ground  on  which  to  rest  a  diagnfisis,  and,  when 
a  mistake  has  been  committed,  has  been  the  chief  source  of  error. 
I  believe  that  a  fibrous  tumor  so  situated  as  to  be  mistaken  tor  a 
haematocele,  will  displace  the  uterus  more  considerably  than  an 


374  DIAGNOSIS,    PROGNOSIS,    AND 

effusion  of  the  same  dimensions,  and  further,  that  such  disphice- 
ment  will  rarely  be  limited  to  the  mere  elevation  of  the  womb, 
and  the  pushing  it  to  one  side,  but  that  the  organ  will  also  be 
retroverted,  or  its  position  will  be  otherwise  manifestly  .changed. 
Time,  however,  will  almost  certainly  remove  the  doubt,  tlie  imme- 
diate solution  of  which  is  seldom  very  urgent;  and  it  must  not  be 
forgotten  that  three-fourths  of  our  diagnostic  errors  arise  from  the 
needless  haste  of  our  decisions. 

Inclusive  of  my  own  eight  cases,  I  have  collected  103  instances 
of  uterine  heematocele,  of  which  20,  or  almost  one-iifth,  proved 
fatal.  There  can,  I  apprehend,  be  little  doubt  but  that  its  usual 
fatality  is  considerably  less  than  would  appear  from  these  imper- 
fect data;  for,  on  the  one  hand,  some  of  the  cases  have  been 
reported  as  pathological  rarities  ;  and  on  the  other,  many  which 
have  had  a  favorable  issue  have  been  unrecorded.  Many,  too, 
have  certainly  passed  unrecognized,  for  the  disposition  to  the 
spontaneous  absorption  of  the  efl'used  blood,  unless  the  quantity 
poured  out  has  been  enormous,  seems  to  be  very  great,  so  that 
menstrual  disorder  and  abdominal  pain  have  probably  often 
passed  away  without  a  suspicion  having  arisen  of  their  connection 
with  hemorrhage  around  the  uterus,  or  into  the  cavity  of  the 
peritoneum. 

The  subjoined  tables  will  throw  light  on  many  points  connected 
with  the  pathology  as  well  as  with  the  treatment  of  the  affection. 

Of  55  cases  of  uterine  hsenuitocele,  treated  on  the  expectant  plan, 
43  recovered,  12  died. 

Of  the  former — 

The  blood  was  absorbed  in, 30 

"           escaped  by  the  rectum  in,    ....  7 

"                 "           "        vagina, 4 

"                 "           "        uterus, 1 

"                 "       into  cavity  of  peritoneum,  .  1 

43 

Of  the  12  deaths— 

1  took  place  from  phthisis. 
1         "  "     phthisis  and  albuminuria. 

1         '<  "     supervention  ot  dysentery. 

1         "  "     great  debility  and   extensive  ab- 

scess of  the  thigh, 

and  are  therefore  only  indirectly  due  to  the  sanguineous  effusion. 
Of  the  remaining  8 — 

1  took  place  from  pya?mia  after  the  tumor  flad  burst  per 
rectum. 

1  "  "     hemorrhage  by  the  bowel. 

2  "  "     hemorrhage  into  the  cyst. 

1         <<  "  "  "  "        and  per  vaginam. 

1  "  "     rupture  into  al)domfn,  and  peritonitis. 

(  peritonitis  without  cyst  rupture,  the  in- 

2  "  "      "I       flanimation  being  acute  in  the  one  case, 

(      and  chronic  in  the  other. 

8 


TREATMENT     OF    UTERINE     H  JE  M  A  T  0  C  E  L  E.  375 

Of  48  cases  iu  which  surgical  interference  was  had  recourse  to, 
40  recovered,  8  died. 

In  38  of  the  40  recoveries,  the  puncture  was  made  h\  tlie 
vagina. 

In  2  of  the  40  recoveries,  the  puncture  was  made  in  tlie  ah(h>- 
men. 

Of  the  8  deaths— 

1  took  place  from  poritonitis  after  puncture  of  the  abdomon. 

In  the  other  cases  the  puncture  was  made 

by  the  vagina. 
1         "  "     cyst  rupture  after  ineffectual  puncture. 

1         "  "     py^Miiia.  symptoms  of  which  had  preceded 

the  ])uncturf'. 

1  "  "     pya'iuia,  foUowini;  the  puncture. 

2  "  "     hemorrhage  through  the  wound. 

1         "  "  "  into  the  sac  after  closure  of  the 

*  punctured  wound. 

1         "  "     peritonitis. 

8 

Lastly,  we  come  to  the  important  question  of  the  appropriate 
treatment  of  this  aflbctioii.  It  happens  rarely,  thouo'li  uiiqucs- 
tionahly  it  does  happen  sometimes,  that  the  hlood  is  ])()ured  out 
in  such  great  ahundance  as  to  occasion  immediate  hazard  to  the 
patient's  life,  and  in  such  circun)stances  the  local  apitlication  of 
cold,  the  employment  of  stimulants,  and  the  use  of  opium,  given 
as  in  cases  of  intestinal  perforation  for  its  stimulant  rather  than 
for  its  sedative  properties,  is  clearly  indicated.'  I  once  saw  a  case 
which  I  imagine  to  have  heen  of  this  kind.  It  occurred  in  a 
woman  hetvveen  thirty  and  forty  years  of  age,  the  mother  of  one 
child,  who  had  for  some  few  times  menstruated  irregularly.  On 
the  third  day  of  an  extremely  abundant  menstruation  she  suddenly 
sank  into  a  state  of  great  exhaustion,  which  the  external  liemor- 
rhage  was  quite  inadequate  to  account  for.  She  fainted,  and  lay 
long  in  a  condition  of  syncope,  her  pulse  was  almost  inn)erc('])til)Ie, 
her  surface  was  as  cold  as  tliat  of  a  patient  in  the  stage  of  collapse 
from  cholera,  and  I  thought  her  dying  when  I  saw  her  al)out  five 
hours  after  these  symptoms  had  come  on.  A  v^iginal  examination 
threw  no  liglit  upon  the  case,  as  no  tumor  was  detected  in  the 
pelvis,  hut  one  feared  that  the  sac  of  an  extra-uterine  fcrtation  had 
hurst,  and  that  the  shock  depended  on  this  cause.  Ice  was  applied 
to  the  vulva  and  over  the  pubes,  opium  and  stimulants  wcvv  ad- 
ministered, and  attention  was  paid  to  kee[»ing  the  surface  \v;irm. 
The  next  morning  I  saw  the  patient  after  an  interval  of  eighteen 
hours.  She  had  rallied  slightly,  and  I  heard,  for  I  never  saw  her 
again,  that  she  slowly  recovered,  without  having  presented  at  any 
time  syni[>toms  of  peritoneal  inflammation. 

Such  occurrences  as  these  are  rare ;  and  usually  the  symptoms 

'  In  a  book  far  less  known  than  it  merits,  Medicnl  Prot>lrn>.i,  by  Messrs.  Griflln, 
of  Limerick,  is  a  most  suggestive  chapter  on  the  use  of  ojiiiim  as  a  stimulant,  which 
should  be  well  studied  by  all  especially  who  are  engaged  in  obstetric  practice 


376  QUESTION    OF    PUNCTURE    IN    TREATMENT 

which  one  has  to  deal  with  are  very  similar  to  those  of  inflamma- 
tion of  the  uterine  appendages,  and  are  to  be  treated  in  the  same 
way,  by  absolute  rest,  by  poultices,  by  sedatives,  and  by  the  careful 
use  of  mercurial  remedies.  "With  the  return  of  each  menstrual 
period,  all  precaution  must  be  redoubled,  since  it  is  under  the 
conditions  of  general  excitement  of  the  circulation  and  special 
congestion  of  the  sexual  organs  which  then  exist,  that  fresh 
hemorrhages  are  apt  to  take  place.  I  have  occasionally  applied 
a  few  leeches  in  the  iliac  region,  when  the  tension  seemed  very 
considerable  and  the  tenderness  extreme,  but  have  never  resorted 
to  large  local  depletion  as  a  means  of  controlling  the  hemorrhage 
and  hastening  the  absorption  of  the  blood  already  effused. 

M.  Aran,'  however,  has  adopted  a  much  more  active  plan,  and, 
as  he  alleges,  %vith  very  remarkable  results.  In  a  case  where  the 
effusion  is  recent,  and  the  constitutional  condition  of  the  patient 
does  not  forbid  it,  he  applies  from  twenty  to  thirty  leeches  over 
the  abdominal  swelling ;  on  the  next  day  from  fifteen  to  twenty 
in  the  same  situation  ;  from  twelve  to  fifteen  on  the  third  day,  if 
the  strength  of  the  patient  admits  of  it;  and  it  is  extremely  seldom 
that  a  fourth  application  is  needed.  The  patients  are  supported 
by  nutritious  diet  while  this  local  depletion  is  carried  out,  and 
this  is  succeeded  as  soon  as  possible  by  the  use  of  blisters  and 
frictions,  or  applications  of  iodine,  to  the  abdomen.  "  By  these 
means,"  says  M.  Aran — and  he  details  cases  in  support  of  his 
assertion — "I  have  reduced  to  fifteen  days  in  some  cases,  to 
from  twenty  to  thirty  in  others  of  a  less  favorable  kind,  the  course 
of  an  affection  wliich  has  been  estimated  by  all  previous  writers 
on  the  subject  at  a  period  of  many  months." 

The  experience  of  one  so  cautious  and  so  trustworthy  as  M. 
Aran  demands  consideration,  and  the  practice  based  on  it  merits 
a  trial. 

But  wdiether  an  antiphlogistic  plan  be  employed  with  more  or 
less  activity,  the  great  question  which  presents  itself  in  a  large 
number  of  instances  concerns  the  expediency  or  inexpediency  of 
surgical  interference.  0{)inion  on  this  point  differed  formerly 
much  more  widely  than  it  does  at  the  present  moment ;  and 
there  seems  now  to  be  a  general  approach  to  unanimity  among 
French  writers  as  to  the  inexpediency  of  meddling  with  these 
collections  of  blood.  The  cases  which  I  have  collected  from  all 
sources,  and  in  doing  which  I  have  been  very  careful  not  to 
reckon  the  same  twice  over,  are  quite  inadequate  to  decide  the 
point.  I  think,  however,  they  tend  to  show  that  the  dangers  of 
puncture  are  less  considerable  than  some  of  its  opponents  have 
supposed  them  to  be;  and  further,  that  tliey  are  of  just  the 
same  kind  as  one  has  to  encounter  in  cases  which  are  left  entirely 
to  nature.^ 

1  Op.  c!t.,  pp.  817-822. 

2  Dr.  M.  Duncan's  cases  are  equally  valuable  as  illustrative  of  the  successful 
puncture  of  these  collections  of  blood,  whether  one  accepts  or  rejects  his  opinion 
as  to  their  ordinary  extra-peritoneal  site. 


OF    UTERINE     HEMATOCELE.  377 

The  much-dreaded  hemorrhage  is  evidently  a  very  exceptional 
occurrence,  and  the  supervention  of  fatal  pyemic  or  peritonitic 
symptoms  is  by  no  means  limited  to  cases  where  interference  has 
been  had  recourse  to.  Still,  these  symptoms  have  unquestionably 
been  lighted  up  by  puncture  of  the  cyst,  even  in  numy  cases 
which  eventually  recovered;  while  the  hazard  of  rupture  into  the 
peritoneum  is  by  no  means  certainly  prevented,  even  though  a 
free  communication  has  been  established  with  the  vagina  or 
rectum.  In  three  out  of  four  of  my  cases,  where  the  cyst  was 
punctured  per  vaginam,  the  operation  was  followed  by  peritoneal 
inflammation,  which  was  once  of  great  severity;  and  the  existence 
of  an  o.pening  in  the  vagina  did  not  in  that  instance  prevent  the 
establishment  of  a  communication  with  the  bowel,  and  the  dis- 
charge of  a  large  quantity  of  blood  per  anum.  Even  an  explora- 
tory puncture  is  not  always  free  from  risk,  as  my  eighth  case 
shows;  while  the  cause  of  its  failure  has  also  been  met  with  in 
other  instances,  where  the  coagulation  of  the  blood  has  formed  a 
thick  layer  of  fibriiie  within  the  sac,  and  has  thus  prevented  the 
escape  of  its  fluid  contents. 

AVeighing  the  results  of  my  own  experience  with  what  I  can 
gather  from  that  of  others,  I  should  be  disposed 

Not  to  puncture  the  cyst — 

1st.  So  long  as  the  effusion  is  recent,  and  there  is  therefore 
reasonable  prospect  of  its  being  absorbed. 

2d.  So  long  as  the  efliision,  although  of  long  standing,  is  in 
course  of  gradual,  even  tliough  very  slow  diminution. 

3d.  For  so  long  as  the  periodical  increase  of  the  effusion  coin- 
ciding with  the  return  of  a  menstrual  epoch,  shows  the  cause 
which  originally  produced  it  to  be  still  in  operation. 

I  should  puncture  the  cyst — 

1st.  When  a  long-standing  effusion  shows  little  or  no  disposi- 
tion to  become  absorbed. 

2d.  When  the  occurrence  of  rigors  and  the  supervention  of 
hectic  symptoms  prove  suppuration  to  have  taken  place ;  and  in 
such  circumstances  I  should  puncture  through  the  abdominal 
walls,  providing  the  swelling  were  not  readily  accessible  by  the 
vasrina. 


378  INFLAMMATION    OF    THE    OVARIES. 


LECTURE    XX  lY. 

DISEASES  OF  PAETS  CONNECTED  WITH  THE  UTEEUS— INFLAM- 
MATION AND  ITS  RESULTS,  AND  KINDRED  PROCESSES. 

Inflammation  or  Uterine  Appendages; — of  the  Ovaries. 

InflaiDmatioii  of  the  ovaries,  iniperf(>ct  state  of  our  knovvli-du;*'.  Morbid  appear- 
ances, inflammation  of  their  peritoneal  surface  fi'equent ;  inflaniination  of  their 
substance  rare  Clianges  produced  by  inflammation  in  the  Graafian  vesicles  ; 
suppuration,  and  ovarian  abscess. 

Symptoms  of  ovarian  inflammation;  of  its  acute  form;  of  abscess  of  the  ovary; 
cases  in  illustration. 

Chronic  inflammatictn  of  the  ovary,  its  frequency  probably  overrated;  neuralijic 
character  of  syini)toms  attributed  to  it.  Occasional  occurrence  of  subacute 
ovaritis;  relation  to  it  of  the  so-called  displacement  of  the  ovary. 

Note  on  Hernia  of  the  Ovary  ;  and  on  Serous  Cysts  of  Uterus. 

Frequently  in  the  course  of  these  Lectures  I  liave  had  occasion 
to  lament  the  incompleteness  of  our  knowledge,  the  imjterfection 
of  the  evidence  on  which  we  are  comitelled  to  act;  and  have  been 
fain  to  content  myself  with  hints  and  suirge.stions ;  with  commu- 
nicating mere  fragments  of  information  where  yet  I  felt  that  defi- 
nite statements  and  positive  rules  were  most  needed. 

Much  of  the  subject  of  to-day's  lecture  can,  I  foar,  be  treated 
by  me  otily  after  tliis  imperfect  fashion,  unless  I  widely  overstep 
the  limits  of  my  own  knowledge,  and  assume  a  positive  air  where 
yet  my  convictions  are  far  from  settled.  Some  facts,  indeed,  are 
well  known  and  universally  admitted,  such  as  the  frequency  of 
acute  ovarian  injlammation  as  a  complication  of  puerperal  peri- 
tonitis, its  rarity  in  other  circumstances;  but  the  frequency,  the 
symptoms,  and  the  importance  of  the  more  chronic  forms  of  in- 
flammation of  the  ovaries,  arc  questions  which  have  received  very 
discordant  replies,  and  for  whose  iinal  decision  data  appear  to  me 
to  be  still  wanting. 

The  difficulties  to  which  I  have  referred  do  not,  indeed,  arise 
from  the  rarity  with  which  morbid  appearanceH  are  discovered  in 
the  ovaries,  but  rather  from  the  uncertainty  whic^h  |)revails  as  to 
their  nature  or  as  to  their  importance.  In  21  out  of  G6  instances 
in  which  I  examined  the  uterus  and  its  appendages  in  the  adult, 
the  ovaries  themselves,  or  parts  immediately  connected  with  them, 
presented  changes  more  or  less  obviously  due  to  inflammatory 
action.  In  10  of  the  21  cases  the  main  evidence  of  inflammation 
consisted  in  traces  of  old  peritonitis  of  the  uterine  appendages, 
and  in  5  of  the  number  there  was  no  evidence  of  other  or  of  more 
recent  mischief.  The  amount  of  this  peritonitis  varied  exceed- 
ingly. In  some  instances  it  was  confined  to  one  side,  and  its 
results  were  nothing  more  considerable  than  a  thin  and  partial 
layer  of  fixlse  membrane  on  the  surface  of  one  or  other  ovary,  and 
long  filamentous  adhesions  between  the  ovary  and  Fallopian  tube. 
In  other  cases  a  complete  web  of  false  membrane  enveloped  the 


INFLAMMATION     OF    THE    OVARIES.  379 

ovaries,  thickened  the  broad  ligaments,  and  by  its  contraction 
shortened  tlie  ovarian  lii^aments,  thus  drawing  the  ovaries  much 
nearer  than  is  natural  to  the  sides  of  the  uterus,  while  at  the  same 
time  they  and  the  Fallopian  tubes  were  iirmly  and  inextricably 
matted  together.  Now  and  then,  too,  the  ovaries  were  not  merely 
drawn  nearer  to  the  uterus,  but  their  position  was  in  other  respects 
changed,  they  being  tied  down  behind  it;  as  in  the  following  notes 
of  the  examination  of  the  body  of  a  woman  who  died  at  the  age 
of  thirty-seven,  of  chronic  bronchitis  and  emphysema,  and  all  of 
whose  four  labors  were  alleged  by  her  husband  to  have  been 
perfectly  natural.  The  uterine  appendages  on  either  side  were 
doubled  back  behind  the  uterus,  and  matted  together  in  that 
situation  by  firm  old  adhesions,  in  the  cellular  tissue  of  which  a 
good  deal  of  firm  granular  fat  was  intermingled.  The  Fallopian 
tubes  of  either  side  were  convoluted,  dilated  to  the  size  of  the  little 
finger,  by  the  presence  in  them  of  a  thick  red  secretion,  like  a 
mixture  of  blood  and  mucus.  Each  was  firmly  adherent  to  its 
coi-responding  ovary,  so  that  it  was  almost  impossible  to  dissect 
them  apart.  Though  twisted  round  as  above  described,  they  did 
not  pass  the  mesial  line,  but  wound  al)out  on  either  side  of  the 
uterus.  On  opening  them  they  presented  the  appearance  of  a 
number  of  freely  communicating  sacculi,  not  unlike  a  section  of 
the  Fucus  marinus ;  and  the  right,  which  was  the  larger  of  the 
two,  measured  at  its  Avidest  part,  whi.*h  was  one  inch  from  the 
uterus,  just  an  inch  and  a  line  when  laid  open.  This  eidarge- 
ment  continued,  though  diminishing,  till  about  a  quarter  of  an 
inch  from  the  uterus,  where  it  ceased  ;  the  short  remainder  of  the 
tubes,  though  pervious,  not  being  wider  than  natural.  The  walls 
of  the  tubes  were  very  dense,  their  muscular  structure  remarkably 
distinct,  and  their  lining  membrane  stout,  tough,  easily  detached 
from  the  subjacent  tissue,  and  presenting  somewhat  of  a  polished 
surface. 

The  left  ovary  was  much  atrophied,  and  was  with  difficulty  dis- 
tinguishable in  the  midst  of  the  thickened  cellular  tissue  and  the 
fat  which  abounded  on  either  side  of  the  uterus  and  within  the 
folds  of  the  l)road  lii^-ament.  The  right  ovary  was  much  larger 
than  natural,  thougii  very  little  of  its  proper  tissue  was  distm- 
guishable.  Its  size,  whieh  was  that  of  an  unshelled  walnut,  was 
chiefly  due  to  a  cyst,  lined  by  a  smooth,  polished  membrane,  and 
filled  with  thick,  grumous  blood,  as  well  as  containing  some  old 
coagulum,  which  required  a  little  force  for  its  detachment. 

In  other  cases  I  have  met  with  a  less  degree  of  the  same  condi- 
tion of  the  uterine  appendages,  and  have  found  the  ovary  wasted, 
api>arently  as  the  result  of  its  compression  by  the  formation  of 
false  membrane  around  it,  an  occurrence  to  which  must  probably 
be  attributed  the  sterility  that  frequently  follows  an  attack  of  i>eri- 
tonitis,  and  the  permanent  8upj>ression  of  the  menses  that  occa- 
sionally, though  less  often,  succeeds  to  the  same  cause. 

Moi-e  important  than  the  changes  produced  by  infiamniatic^n  on 
the  exterior  of  the  ovarv  are  those  alterations  which  it  causes  in 


380  CHANGES    OF    THE    OVARIES 

their  substance,  and  especially  in  the  Graafian  vesicles.  The  mere 
substance  of  the  ovaries  does  not,  indeed,  except  in  the  puerperal 
state,  often  present  appearances  indicative  of  inflammation  or  of 
its  results.  The  softening  of  their  tissue,  the  infiltration  with  pus 
— which  is  sometimes  poured  out  so  suddenly  and  in  such  al)un- 
dance  as  to  produce  rupture  of  the  organs — or  that  sloughing  of 
their  substance  occasionally  observed  in  the  bodies  of  w^omen  who 
have  died  during  epidemics  of  puerperal  fever,  are  conditions 
which,  to  the  best  of  my  knowledge,  are  not  met  with  in  the  un- 
impregnated  state.  Afl'ections  of  the  ovarian  tissue,  apart  from 
the  puerperal  condition,  are,  I  believe,  almost  always  secondary 
and  subordinate  to  those  of  the  Graafian  vesicles  themselves. 
Thus,  when  the  functions  of  the  ovaries  are  no  longer  exercised, 
and  ovules  are  not  in  course  of  ]U'odncti()n  and  maturation,  we 
find  the  substance  of  the  organs  shrunken,  dense,  and  frorpiently 
intersected  by  white  lines  of  firm  cellular  tissue;  and  just  in  a 
similar  way  do  we  find  it  swollen,  congested,  and  infiltrated,  in 
conjunction  wnth  a  turgid  state  of  the  Graafian  vesicles,  and  with 
the  presence  of  evidences  of  ijiflamnnition  about  their  coats.  In 
these  circumstances,  indeed,  we  find  the  whole  of  the  ovary  con- 
siderably increased  in  size ;  but  m}-  own  experience  corresponds 
with  that  of  Kiwisch,  who  says  that  it  is  extremely  unusual  for 
the  organ  in  the  unimpregnated  condition  to  be  enlarged  by  any 
inflammatory  atFection  of  its  stroma  to  more  than  double  its  nat- 
ural size.' 

It  is  in  the  Graafian  vesicles  themselves  that  we  find,  as  indeed 
might  be  anticipated,  the  most  important  results  of  inflammation  ; 
and  such  inflammation  is  of  great  moment,  from  the  circumstance 
that  in  some  instances  it  is  probably  the  first  step  in  the  produc- 
tion of  ovarian  dropsy.  In  the  case  of  women  who  have  died 
during  or  soon  after  menstruation,  it  is,  as  you  know,  very  usual 
to  find  a  state  of  general  turgescence  of  one  or  other  ovary,  with 
great  prominence  of  some  of  the  Graafian  vesicles,  and  minute 
injection  of  their  external  membrane,  while  a  large  clot  occupies 
the  cavity  of  that  one  of  the  vesicles  from  which  the  ovule  has 
escaped.  Such  appearances  of  the  ovary  are  physiological,  and 
pass  away  with  the  subsidence  of  the  periodical  congestion  that 
produced  them,  the  clot  itself  being  gradually  removed,  and  the 
contracted  vesicle  disappearing  by  degrees.  Appearances  of  a 
somewhat  similar  kind  are  met  with,  however,  independent  of 
menstruation,  and  in  circumstances  that  point  directly  to  inflam- 
mation as  their  cause.  Thus,  in  the  case  of  a  prostitute,  twenty 
years  of  age,  who  w^as  suftering  from  severe  gonorrhoea  at  the  time 
of  her  death  from  pleuro-pneumonia,  the  whole  interior  of  the 
cavity  of  the  uterus  was  covered  by  a  copious  puriform  secretion, 
the  surface  beneath  being  of  a  briglit  red,  just  like  red  velvet. 
This  condition  ceased  abruptly  wdiere  the  plicated  structure  of  the 
cervix  uteri  began,  but  was  continued  along  the  whole  tract  of  the 

1  Op.  cit.,  vol.  ii,  second  edition,  p.  47. 


PRODUCED     BY     INFLAMMATION.  381 

Fallopian  tubes.  They  were  pervious  at  their  uterine  ends,  oblit- 
erated at  their  fimbriated  extremities,  filled  with  thick  pus,  which 
had  distended  the  fimbriae  into  little  pouches,  while  their  lining 
membrane  was  of  a  finely  flocculent  appearance,  and  of  the  most 
vivid  red.  The  ovaries  were  rather  birge;  they  were  somewhat 
congested,  the  Graafian  vesicles  were  both  numerous  and  turgid, 
and  their  membrane  presented  a  most  beautiful  appearance,  being 
traversed  by  very  minute  vessels,  and  looking  as  if  the  finest  ver- 
milion injection  had  been  thrown  into  them. 

I  do  not  knov/  exactly  what  the  subsequent  stage  of  the  disease 
would  have  been  if  the  patient's  life  had  not  been  cut  short  by 
the  pneumonia.  Probably,  however,  the  contents  of  the  vesicles 
would  next  have  been  ohyiously  changed,  and  in  all  likelihood 
would  have  eventually  become  purulent.  Such  at  least  were  the 
contents  of  many  of  the  Graafian  vesicles  in  the  right  ovary  of  a 
girl  who  died  of  very  acute  peritonitis;  and  in  whom  there  was 
found  a  cyst  distended  with  pus,  of  the  size  of  an  orange,  connected 
with  that  organ,  while  many  of  the  Graafian  vesicles  contained 
little  drops  of  pus,  though  there  was  no  suppuration  of  its  general 
tissue,  and  the  other  ovary  was  quite  healthy. 

The  large  cyst  in  this  case  had  probably  existed  for  a  long  time 
before  the  commencement  of  the  patient's  fatal  illness,  and  the 
supervention  of  inflammation  in  it  was  very  likely  the  point  of 
departure  of  all  the  subsequent  mischief  As  we  shall  have  occa- 
sion hereafter  to  observe,  the  occurrence  of  inflammation  and  sup- 
puration in  an  ovarian  cyst  is  an  accident  by  no  means  unusual, 
and  one  which  sometimes  takes  place  without  giving  rise  to  symp- 
toms so  severe  as  might  have  been  anticipated.  Such  cases,  how- 
ever, are  perfectly  distinct  from  those  of  primary  ovarian  abscess, 
which  latter  are  also,  I  believe,  of  much  greater  rarity.  For  the 
most  part  the  increase  of  such  abscesses  generally  goes  on  rather 
slowly,  and  their  development  is  usually  attended  with  symptoms 
of  for  more  serious  constitutional  disturbance  than  accompanies 
the  growth  of  an  ordinary  ovarian  cyst;  though  after  a  time  they 
not  seldom  become  stationary,  and  remain  so  even  for  years. 
Thus,  in  the  case  of  a  patient  who  died  twelve  years  after  her  first 
attack  of  inflammation  of  the  uterine  appendages,  and  four  years 
after  her  second  and  last  seizure  of  a  similar  kind,  the  right  ovary 
was  beset  with  numerous  yellow  dots  of  a  matter  which  looked 
like  softened  cheese,  probably  the  result  of  some  change  in  the 
contents  of  the  Graafian  vesicles,  while  the  left  ovary,  to  which 
the  corresponding  tube  was  firmly  adherent,  formed  an  abscess 
the  size  of  an  orange  and  lull  of  pus.  The  cavity  of  this  abscess 
was  sinuous,  as  if  several  collections  of  pus  hid  eventually  been 
fused  by  the  removal  of  their  septa  into  one,  and  at  its  lower  part 
there  was  a  mass  of  cretaceous  matter  of  the  size  ola  chestnut. 

There  are,  besides,  some  appearances  of  no  great  rarity  i»resonted 
by  the  Graafian  vesicles,  whicli  have  been  sujtposed,  aiid  with  con- 
siderable probability,  to  be  the  results  of  a  chronic,  or,  at  any  rate, 
of  a  bygone  inflammation.     Such  is  the  loss  of  transparency  of 


882  ACUTE     OVARITIS. 

tlie  coats  of  the  vesicles,  and  especially  their  entire  conversion  into 
firm,  whitish,  or  yellowish-white,  shot  like  bodies,  of  the  size  of  a 
small  pea,  and  of  a  homogeneous,  somewhat  friable,  texture.  In 
some  instances  the  stroma  of  the  ovaries  has  appeared  unaltered 
around  tliese  bodies,  but  at  other  times  I  have  found  it  also  the 
seat  of  a  yellow  matter  like  fibrine,  either  infiltrated  into  the  centre 
of  the  organ  or  deposited  in  stride  which  intersected  its  tissue. 
This  condition,  too,  has  always  been  associated  with  considerable 
thickening  of  the  ovarian  capsule,  and  with  a  dead  white  color  of 
its  surface ;  and  the  ovary  generally  has  been  small  and  shrunken, 
and  contained  lew  Graafian  vesicles,  and  sometimes  none  but  those 
which  had  been  the  subject  of  this  cliange.  It  is  not,  however,  as 
might  be  supposed,  a  result  of  mere  wasting  from  the  advance  of 
age  and  the  cessation  of  the  generative  function,  for  I  have  met 
wnth  this  state  in  the  body  of  a  woman  who  died  at  the  age  of 
twenty-five,  and  in  whose  ovaries  there  were  not  merely  other 
healthy  Graafian  vesicles,  but  also  in  one  a  large  menstrual  clot, 
and  other  evidences  of  i-eeent  menstruation. 

Acute  irifiummation  of  the  substance  of  the  unimpregnated  ovary 
is  of  such  rare  occurrence  that  no  case  lias  come  under  m>'  own 
care,  and  but  one  has  presented  itself  to  my  observation.  To  that 
case  I  have  already  referred,  as  afibrding  an  instance  of  suppura- 
tion in  the  Graafian  follicles  themselves,  but  the  cause  of  death 
was  the  supervention  of  general  [leritonitis. 

The  patient's  history  a  fiord  ed  no  clue  to  the  cause  of  her  illness, 
for  she  was  a  young  unmarried  woman,  eighteen  years  old,  living 
in  comfort  as  a  domestic  servant,  and  never  having  had  any  dis- 
order of  her  catamenia,  or  any  uterine  ailment.  Her  illness  had 
come  on  spontaneously  four  or  five  daj's  before  her  admission  into 
the  hospital,  and  not  at  a  menstrual  period,  with  }»ain  in  the  back 
and  abdomen,  fever  and  languor,  for  which,  however,  no  treatment 
W'as  adopted  before  she  entered  the  hospital,  ller  symptoms  were 
just  those  of  general  peritonitis;  a  dry  skin,  a  small  pulse  of  120, 
urgent  thirst,  and  constant  sickness,  great  headache,  a  full,  tense, 
and  tender  abdomen,  and  much  pain  in  the  abdomen  and  back. 
Her  condition  did  not  seem  to  admit  of  active  treatment,  and  the 
next  day  the  pulse  had  risen  to  160,  the  sickness  was  incessant, 
the  matter  vomited  being  of  a  dark  greenish  color;  the  abdomen 
was  more  tense,  its  tenderness  undiminished,  but  the  pain  now 
recurred  in  paroxysms,  between  which  were  intervals  of  compara- 
tive ease.  In  eighteen  hours  more  she  died — about  forty  hours 
from  her  admission  into  the  hospital. 

There  was  universal  peritonitis;  two  pints  of  purulent  fluid 
were  present  in  the  abdominal  cavity ;  and  inflammation  had  ex- 
tended to  the  diaphragmatic  pleura.  The  uterus  and  the  left  ovary 
were  perfectly  healthy.  Connected  with  the  right  ovary  was  a 
cyst  filled  with  pus,  which  reached  as  high  as  the  brim  of  the 
pelvis,  and  pus  coated  the  outer  surface  of  the  ovary  as  well  as 
occupied  the  Graafian  vesicles. 

So  rapid  a  course  of  the  disease,  and  so  serious  a  termination 


ABSCESS    OF    THE     OVARY.  383 

of  it,  arc  of  great  rarity.  Inflammation  commencing  about  tlie 
.  uterine  appendages  on  either  side  seldom  extends  beyond  the  peri- 
toneum in  the  immediate  vicinity  of  the  uterus;  and  even  when 
the  substance  of  the  ovary  is  affected,  and  inflammation  ends  in 
sup[)uration,  it  is  for  the  most  part  from  a  slow  and  wasting  illness 
that  the  patient  sutlers;  the  abacess  attaining  a  very  large  size, 
and  possildy  even  i)ersisting  for  years.  Such  at  least  is  the  expe- 
rience of  Kiwisch,'  and  my  own  more  limited  observation  leads 
me  to  the  same  opinion.  lie  notices  the  disposition  of  the  symp- 
toms to  come  to  a  standstill,  so  that  sometimes  the  patient  suffers 
chiefly  from  the  mechanical  inconvenience  of  the  tumor,  while  in 
other  instances  the  arrest  of  the  symptoms  is  of  a  more  im]»erfect 
kind:  the  patient  continues  to  lose  flesh;  occasional  febrile  at- 
tacks come  on,  till  at  length  a  condition  of  hectic  manifests  itself, 
indicative  in  many  instances  of  decomposition  of  the  contents  of 
the  abscess,  and  death  takes  place  either  before  or  soon  after  it 
has  discharged  itself  All  of  these  occurrences  have  come  under 
my  observation  in  cases  of  ovarian  cysts  in  which  inflammation 
has  supervened,  converting  their  contents  into  purulent  matter; 
but  I  have  only  once  met  with  an  instance  in  which  there  was 
reason  to  believe  that  the  tumor  had  been  from  the  commence- 
ment an  abscess,  and  had  not  originated  in  the  inflammation  of 
the  cyst-wall  of  a  dro[»sical  ovarium.  In  this  instance  the  patient's 
illness  commenced  with  suppression  of  the  menses  five  months 
after  marriage,  she  being  at  that  time  twenty-six  years  old.  The 
suppression  of  her  menses  was  followed  by  pain  in  the  right  side 
of  the  abdomen,  about  the  situation  of  the  crista  ilii,  but  extend- 
ing to  the  opposite  side,  aggravated  by  motion  or  exertion,  and 
confining  her  by  its  severity,  and  by  the  general  constitutional 
disorder  which  accom[ianied  it,  almost  constantly  to  bed  during 
the  six  months  which  preceded  her  admission  into  the  hospital. 
Very  soon  after  the  commencement  of  her  illness  a  tumor  ap- 
peared in  the  right  iliac  region,  which  was  said  by  her  medical 
attendant  to  be  an  abscess.  A  month  after  the  swelling  was  first 
perceived  a  discharge  of  pus  took  place  from  the  urethra,  which 
continued  at  intervals  for  some  weeks,  though  without  any  marked 
change  in  the  swelling.  The  discharge  then  ceased  for  a  time,  but 
at  the  end  of  three  months  it  again  recurred,  and  continued  to  take 
place  occasionally  until  the  patient  came  under  my  care,  though 
in  spite  of  this,  the  tumor  had  gone  on  slowly  increasing  in  size. 

On  her  admission  the  patient  looked  very  ill,  her  countenance 
Avas  anxious,  her  i»ulse  fre(pient,  her  tongue  red  at  the  tip  and 
edges,  and  thiekly  covered  with  ajihtha?.  Her  abdomen  measured 
twenty-eight  inches  in  circumferL'iice  at  the  umbilicus,  its  cnlarge- 
ment  being  due  to  a  pyriform  tumor  in  the  mesial  line,  which 

'  Kiwisch,  op.  cit  ,  vol.  ii,  p.  07,  mentions  having  seen  nn  abscess  of  the  ovary 
wliicl)  contained  sixteen  pints  of  pus.  I  have  seen  tiiirty-five  |)ints  of  pure  pus 
f'vacujiie<l  from  an  ovarian  cyst;  but  tliis  was  in  a  ca^e  of  dro|>sy,  in  which  in- 
flammation of  the  cyst-wall  had  supervened,  an  accident  to  which  further  reference 
will  lie  made  in  another  lecture. 


384  ABSCESS    OF    THE    OVARY. 

occupied  the  hypogastric,  umbihcal,  and  lower  part  of  the  epigas- 
tric regions,  and  extended  laterally  to  the  lumbar  and  lower  part 
of  the  hypochondriac  regions.  The  tumor  yielded  a  distinct  sense 
of  fluctuation,  and  was  very  tender  on  pressure,  especially  in  the 
hypogastric  region.  The  uterus  was  low  down,  and  carried  for- 
wards nearer  than  natural  to  the  anterior  pelvic  walls.  It  did  not 
seem  to  be  altered  or  enlarged,  neither  was  it  fixed  in  the  pelvis, 
nor  was  there  any  thickening  of  the  vaginal  walls.  The  move- 
ments of  the  organ  were,  however,  im[)eded  by  some  tumor, 
which,  though  not  dipping  down  into  the  pelvic  cavity,  nor  pre- 
senting any  distinct  outline,  was  yet  to  be  felt  as  ottering  a  gen- 
eral resistance  on  pressure  being  made  in  any  direction  against  the 
roof  of  the  vagina. 

Three  weeks  after  the  patient's  admission  pus  began  to  be  dis- 
charged from  the  bowel,  and  in  the  course  of  a  little  more  than  a 
fortnight,  under  the  continuance  of  these  discharges  the  tumor 
almost  entirely  disappeared,  though  much  pain  continued  to  be 
felt  in  the  right  iliac  region,  and  a  little  i)us  occasionally  re- 
collected in  the  sac  of  the  abscess,  and  was  from  time  to  time 
discharged  per  rectum.  The  progress  of  her  recovery  was  re- 
tarded by  an  attack  of  phlegmasia  dolens  of  the  left  leg ;  but 
about  two  months  after  her  reception  into  the  hospital  she  was 
discharged  perfectly  well,  and  no  trace  of  the  tumor  was  to  be 
detected  anywhere. 

In  this  case  the  suddenness  of  the  attack,  tlie  acute  character  of 
the  symptoms  which  attended  its  onset,  and  the  rajiid  formation 
of  the  tumor,  are  alike  incompatible  with  the  sujiposition  that  the 
case  was  one  of  dropsy  of  the  ovary.  On  the  other  hand,  the  situa- 
tion of  the  swelling  in  the  abdomen,  the  mobility  of  the  uterus 
and  the  absence  of  thickening  by  the  side  of  the  womb,  or  at  the 
roof  of  the  vagina,  clearly  show  that  the  case  was  not  one  of  pelvic 
abscess,  or  of  inflammation  of  the  celiular  tissue  within  the  folds 
of  the  broad  ligament.  We  thus  arrive  at  the  conclusion  that  the 
matter  was  secreted  irom  an  abscess  in  tlie  ovary  due  to  inflam- 
mation excited  in  all  probability  by  the  sudden  suppression  of  the 
menses  which  marked  the  commencement  of  the  patient's  illness. 

I  do  not  know  that  practically  there  is  very  much  to  gather 
from  the  details  of  a  case  such  as  the  j)receding  beyond  the  knowl- 
edge of  the  fact  that  acute  ovaritis,  ending  in  sujjpuration,  may 
come  on  without  apparent  cause,  and  that  the  tumor  thus  formed 
may  acquire  a  great  size,  and  may  present  all  the  characters  of  a 
dropsical  ovary.  As  far  as  treatment  is  concerned,  it  would,  I 
think,  in  the  case  last  related,  have  been  the  wiser  course  to  liave 
punctured  the  tumor  and  have  evacuated  its  contents  soon  after 
the  patient's  admission. 

It  is  not  from  the  observation  of  cases  such  as  have  hitherto 
been  related,  and  which  are  confessedly  as  rare  in  their  occurrence 
as  they  are  formidable  in  their  character,  that  has  arisen  the  general 
impression  of  the  importance  and  the  frequency  of  ovarian  inflam- 
mation.    The  ovaritis  which  is  chiefly  dwelt  on  by  medical  writers 


CHRONIC    OVARITIS.  385 

is  paid,  for  the  most  part,  to  be  eitlier  subacute  or  chronic  in  its 
character.  It  is  an  affection  supposed  to  be  capable  of  lasting  for 
many  years  without  leading  to  any  grave  alteration  of  structure, 
though  occasioning  mucli  functional  disorder,  and  producing  much 
local  suffering.  Disturbance  of  menstruation  of  various  kinds, 
sterility,  and  pain  in  the  abdomen,  more  especially  pain  referred 
to  one  or  other  iliac  region,  are  the  symptoms  commonly  assigned 
to  this  chronic  ovaritis;  and,  indeed,  a  very  large  proportion  of  the 
ailments  that  have  been  referred  by  some  observers  to  inflammation 
of  the  cervix  uteri,  and  ulceration  of  its  orifice,  have  been  attrilmted 
by  others  equally  confidently  to  chronic  inflammation  of  the  ovary. 

My  own  impression  is,  that  a  larger  share  has  been  assigned  to 
chronic  inflammation  in  the  production  of  these  symptoms  than 
can  be  proved  to  be  really  due  to  it.  In  no  class  of  ailments  is 
pain  so  incorrect  an  index  to  the  nature  and  importance  of  the 
morbific  process  which  gives  rise  to  it  as  in  the  disorders  of  the 
sexual  system  of  women.  On  the  one  hand,  diseases  of  the  most 
formidable  character  sometimes  run  their  course  without  the  pro- 
duction of  any  suffering  till  they  reach  a  stage  utterly  beyond 
remedy,  while,  on  the  other  hand,  pains  of  the  severest  kind  recur 
in  some  instances  for  weeks  or  months,  or  even  for  years,  and  yet 
neither  during  life  nor  after  death  can  any  adequate  explanation 
be  discovered  of  their  occurrence  or  their  persistence.  It  seems, 
indeed,  as  if  the  sorrow  which  women  are  peculiarly  heirs  to  were 
not  confined  to  the  time  of  parturition,  but  as  if  the  sentence  ex- 
tended in  a  measure  to  the  performance  of  all  the  sexual  functions. 
Pregnancy  and  menstruation,  as  well  as  childbearing,  are  very 
generally  times  of  suti'ering,  and  sexual  intercourse  itself  is  not 
infrequently  attended  or  followed  by  the  same  kind  of  pain  as 
has  been  referred  to  ovarian  inflammation.  Pain  in  the  ovarian 
region  is  a  very  general  attendant  on  prolapse  of  the  womb,  and 
it  suflices  but  to  introduce  the  sound  into  the  cavity  of  the  uterus 
in  order  to  produce,  and  often  with  great  intensity,  pain  referred 
to  the  situation  of  the  ovaries. 

But  while  such  symptoms  are  of  frequent  occurrence,  are  some- 
times as  causelessly  persistent  as  in  others  they  are  causelessly 
evanescent,  the  researches  of  morbid  anatomists  do  not  make  us 
acquainted  with  such  changes  in  the  ovaries  as  can  be  sup[)08ed 
to  occasion  them.  We  often,  indeed,  find  the  evidences  of  circum- 
scribed peritonitis  about  the  ovaries,  but  we  find  them  in  cases 
where  there  have  been  no  symptoms  of  an  urgent  character  during 
life,  often  indeed  where  no  symptom  of  any  kind  has  existed.  But 
with  the  exception  of  those  evidences  of  inflammatory  action  on 
the  serous  surface  of  the  ovaries,  the  signs  of  a  morljid  process, 
too,  which  must  soon  have  run  its  course,  there  are  but  few 
changes  in  those  organs  which  an  examination  after  death  re- 
veals, and  those  limited,  or  nearly  so,  to  the  Graafian  vesicles, 
and  usually  to  a  few  only  of  their  number.  In  many  of  the  in- 
stances, too,  where  such  appearances  are  discovered,  it  has  been 
matter  of  absolute  certainty  that  during  life  all  the  sexual  func- 

25 


386  OVARIAN    PAIN    OFTEN 

tions  were  performed  with  complete  regularity,  and  without  any 
suttcring.  I  could  not  acquiesce  in  the  opinion  that  almost  all 
the  numerous  ills  of  womanhood  are  due  to  inflammation  of  the 
neck  of  the  womb.  I  can  as  little  see  in  them  the  evidence  of 
ovarian  inflammation,  and  I  believe  that  in  "nineteen  cases  out 
of  twenty  in  which  the  ovarian  regions  are  the  seat  of  deep,  dull, 
aching  pain,  and  appear  tender  and  rather  swollen,  there  is  no 
actual  ovarian  disease  whatever."*  I  cannot  finish  the  sentence 
by  saying  with  the  author  whose  words  I  have  quoted,  that  the 
symptoms  are  almost  invariably  the  result  of  some  uterine  lesion, 
for  1  believe  that  in  many  cases  the  symptoms  are  purely  neuralgic 
in  their  character,  independent  of  any  local  lesion,  and  curable 
less  by  local  treatment  than  by  remedies  addressed  to  the  general 
state  of  the  constitution. 

My  opinions  on  this  subject,  indeed,  correspond  very  closely 
with  those  expressed  by  Dr.  Churchill,^  of  Dublin,  who  has  de- 
scribed this  class  of  affections  as  the  result  of  ovarian  irritation. 
To  this  term,  for  my  own  part,  I  see  no  kind  of  objection,  though, 
if  preferred,  the  simpler  designation  of  ovarian  pain  will  answer 
every  purpose,  and  serve  equally  well  to  impress  upon  your  minds 
the  fact  that  mere  suffering  does  not  of  necessity  imply  either  the 
presence  or  the  previous  existence  of  inflammation.  Pain  is  in 
itself  the  patient's  ailment,  and  this  even  varies  greatly  in  diflerent 
persons,  and  causelessly  and  within  very  short  intervals  in  the 
same  person  both  in  its  character  and  intensity.  It  is  ordinarily 
dull  and  aching,  is  accompanied  by  tenderness  in  the  iliac  region, 
in  which  situation  a  degree  of  fulness  may  often  be  detected, 
though  careful  percussion  will  discover  that  this  fulness  is  due 
rather  to  the  presence  of  flatus  in  the  intestines  than  to  the  ex- 
istence of  any  solid  tumor.  Though  this  pain  seldom  subsides 
com|iletely,  it  is  apt  to  be  increased  in  paroxysms;  walking, 
riding,  exertion  of  any  kind,  and  sometimes  even  the  remaining 
for  a  short  time  in  the  erect  posture,  considerably  aggravating  it. 
Menstruation  almost  always  adds  greatly  to  its  severity,  and  sexual 
intercourse  nearl}^  invariably  increases  it,  sometimes  even  induces 
a  pnroxysm  of  great  violence.  The  extent  of  the  pain  is  very  va- 
riable. Always  severest  in  the  situation  of  one  or  other  ovary 
(and  for^ome  unexplained  reason  generally  in  the  situation  of  the 
left),  it  is  sometimes  limited  to  that  spot,  but  in  other  cases  ex- 
tends more  or  less  to  all  the  pelvic  viscera ;  difficult,  frequent  and 
painful  micturition  are  then  always  experienced,  and  defecation  is 
likewise  often  attended  or  followed  l)y  severe  suflering.  While 
pressure  in  the  iliac  region  is  always  painful,  a  vaginal  examina- 
tion sometimes  causes  little  inconvenience.  In  other  cases,  how- 
ever, it  is  productive  of  pain  which  lasts  for  several  hours,  and 
this  even  though  no  trace  of  disease  may  be  detected.  In  some 
instances,  indeed,  in  which  the  suffering  produced  by  examination 

1  Dr.  H.  Bennet,  op.  cit,  p.  222. 

*  Dublin  Medical  Journal,  vol.  xii,  August,  1851,  p.  82. 


INDEPENDENT    OF    INFLAMMATION.  387 

was  most  severe,  the  uterus  was  smaller  than  natural,  a  condition 
which,  when  coupled  with  the  sterility  of  the  patient,  seemed  to 
indicate  an  imperfect  development  of  the  whole  sexual  system. 
In  those  instances  where  the  patient's  sufierings  were  severest, 
there  were  almost  always  unmistakahle  signs  of  the  hysterical 
temperament — often  very  ohvious  symptoms  of  hysteria — while 
even  when  this  was  not  the  case,  the  sudden  aggravation  or 
sudden  cessation  of  the  pain  was  sufficiently  characteristic  of  its 
neuralgic  character. 

Though  frequently  independent  of  actual  disease,  pain  such  as 
has  been  described  is  also,  in  a  very  large  number  of  cases,  a  con- 
comitant or  sequela  of  various  uterine  ailments.  Of  course,  when 
disease  of  any  kind  exists,  its  removal  forms  our  first  duty  ;  but 
even  when  this  has  been  effected,  the  pain  often  outlasts  the  cause 
which  first  excited  it ;  or  when  it  seems  to  have  completely  dis- 
appeared, may  return  during  menstruation,  or  be  rekindled  by  any 
imi»rudent  exertion,  or  Iry  sexual  intercourse. 

Just  like  that  backache  which  bears  so  large  a  part  among  the 
minor  ills  of  women,  so  tliis  ovarian  pain,  while  easy  to  mitigate, 
is  very  hard  to  cure.  Leeches  do  not  relieve  it,  or  if  they  give 
any  ease,  it  is  only  for  a  few  hours,  and  the  pain  then  returns  as 
severely  as  before.  Blisters  sometimes  afford  ease,  though  not 
often  in  those  cases  where  the  pain  is  most  severe,  while  sometimes 
they  seem  rather  to  aggravate  discomfort  by  the  soreness  of  the 
surface  which  they  occasion.  In  some  instances  I  have  found 
great  comfort  experienced  from  constantly  wearing  a  wet  compress 
on  the  painful  side  of  the  abdomen.  Chloroform  applied  to  the 
side  generally  gives  temporary  relief,  even  when  the  paroxysms 
of  pain  are  most  severe  ;  while  a  piece  of  lint  soaked  in  a  mixture 
of  ((pial  parts  of  chloroform  and  oil.  and  covered  with  a  piece  of 
oiled  silk,  is  an  application  which,  while  in  bed,  the  patient  may 
employ  constantly  with  much  benefit.  Tlie  camphor  liniment, 
with  extract  of  belladonna,  or  the  Linimentum  Belladonufe  of  the 
new  Pharniaco|)Oeia,  is  another  external  ajiplication  which  I  have 
fourid  advantageous;  and  when  these  means  have  been  fruitless, 
I  have  emplo3'ed  the  tincture  of  aconite  with  advantage,  a})[)lying 
the  undiluted  tincture  by  means  of  a  brush,  or  laying  a  piece  of 
lint  soaked  in  it  over  the  seat  of  pain. 

These  symptoms  sometimes  wear  themselves  out,  the  pain  by 
degrees  subsiding  as  the  patient's  general  health  improves  :  but  I 
have  never  been  able  to  trace  the  permanent  cessation  of  sulVering 
to  the  unaided  use  of  any  local  measures.  St)me  caution,  ttu),  is 
necessary  in  their  employment,  for  as  with  many  neuralgic  and 
almost  all  hysterical  pains,  so  here  any  kind  of  local  treatment 
which  directs  the  patient's  attention  very  much  to  the  seat  of  her 
sufferings  is  apt  to  defeat  its  own  object,  and  to  perpetuate  the 
evil  instead  of  removing  it.  Attention  to  thegeneral  health  must 
always  go  hand  in  hand  with  the  local  treatnu-nt  — must  indeed,  I 
think,  hold  the  first  place.  It  would  be  useless  to  endeavor  to 
go  into  long  detail  here  with  reference  to  this  subject.     1  will  only 


388  INFLAMMATION    OF    THE    OVARIES. 

observe  that  there  are  two  tonics  which  in  cases  of  this  kind 
generally  do  the  most  service.  One  of  them  is  the  sulphate  of 
quinine,  which,  when  tolerated  by  the  patient,  does  the  same 
kind  of  good  as  in  other  cases  of  neuralgic  pain,  though  not  so 
certainly,  nor  to  the  same  extent.  The  other  is  the  valerianate 
of  zinc,  to  which  I  generally  have  recourse,  wherever  quinine  is 
contraindicated  or  cannot  be  borne.  I  know  of  but  one  drawback 
from  its  employment,  and  that  is  the  permanent  taste  which  it  is 
apt  to  leave  in  the  mouth,  and  the  unpleasant  eructations  with 
which  patients  are  sometimes  troubled  hours  after  it  has  been 
taken,  though  when  given  in  the  form  of  a  pill  silvered  this  incon- 
venience is  often  avoided.  There  are  indeed  some  cases,  though 
I  believe  their  number  to  be  inconsiderable,  in  which  the  exist- 
ence of  inflammation  of  the  ovaries  is  less  questionable.  The  attack 
in  these  cases  is  usually  definite  in  its  onset,  and  for  the  most 
part  succeeds  either  to  sudden  suppression  of  the  menses,  or 
follows  at  least  some  considerable  disturbance  of  the  menstrual 
function,  or  occasionally  comes  on  not  very  long  after  a  miscar- 
riage, though  once  or  twice  I  have  met  witli  the  affection  with- 
out being  able  to  assign  any  probable  cause  for  its  occurrence. 
General  febrile  disturbance,  usually  of  no  great  intensity,  and  by 
no  means  invariably  ushered  in  by  shivering,  is  accompanied  by 
pain  referred  to  the  hypogastrium,  or  to  one  or  other  iliac  region, 
and  by  frequent  desire  to  pass  water,  which  is  usually  high- 
colored  and  deposits  lithates.  In  the  main,  indeed,  the  symptoms 
are  such  as  attend  an  attack  of  uterine  inflammation,  except  per- 
haps that  they  are  less  severe.  A  vaginal  examination  suffices  to 
show  that  the  uterus  is  not  the  part  affected,  for  though  the  heat 
of  the  vagina  may  be  somewhat  increased,  the  womb  is  neither 
enlarged  nor  tender,  nor  are  its  lips  pufly  ;  while,  at  the  same 
time,  pressure  against  the  roof  of  the  vagina,  at  one  or  other  side 
of  the  womb,  not  only  produces  considerable  pain,  but  very  often 
detects  the  indistinct  outline  of  the  enlarged  ovary.  Sometimes, 
indeed,  the  ovary  may  be  very  clearly  felt,  especially  if,  as  is 
usually  the  case,  it  occupies  the  cul-de-sac  between  the  uterus  and 
rectum,  and  it  may  then  be  much  more  clearly  distinguished  by 
the  finger,  introduced  into  the  bowel  than  by  a  mere  vaginal  ex- 
amination.^ The  general  symptoms,  combined  with  the  absence 
of  affection  of  the  uterus,  and  the  pain  on  pressure  at  its  side, 
suffice  to  point  to  the  ovary  as  the  seat  of  the  patient's  sufferings. 
When  the  tumor  can  be  distinguished,  it  may  be  recognized  as 
the  ovary  by  its  oval  shape,  its  smooth  surface,  its  elasticity,  a 
certain  degree  of  mobility,  of  which  it  is  found  susceptible,  as 
well  as  by  the  peculiar  sickening  sensation  which  pressure  upon 
it  produces.  ' 

These  symptoms  for  the  most  part  have  a  sufficiently  active 

'  Dr.  Lowcnhardt  was  the  first  person  to  draw  special  attention,  in  his  Diagnos- 
tiseh-praktificJie  AhhcnicUungen^  &c.,  8vo.,  Prenzlau,  1835,  p.  297,  to  these  cases  of 
ovarian  inflammation,  and  to  the  value  of  examination  per  rectum  as  a  means  of 
diagnosis. 


DISPLACEMENT    OF    THE    OVARY.  389 

character  to  enforce  the  patient's  attention,  while  tlie  employment 
of  local  leeching,  of  the  tepid  hip-bath,  the  use  of  anochaie  and 
mild  antiphlogistic  remedies,  and  the  observance  of  absolute  rest 
— the  same  remedies,  in  short,  as  would  be  applicable  in  cases  of 
inflammation  of  the  uterus  itself — generally  suflice  for  their  re- 
moval in  the  course  of  a  few  days. 

Some  exceptional  cases  are,  however,  occasionally  met  with,  in 
which,  in  a  somewhat  mitigated  form,  the  above-mentioned  s^nup- 
toms  continue  for  months  or  years,  and  are  found  to  be  associated 
with  the  presence  of  the  enlarged  and  congested  ovary  in  the  cul- 
de-sac  between  the  uterus  and  rectum.  The  late  Dr.  Rigby'  was, 
I  believe,  the  first  person  who  drew  attention  to  this  condition 
under  the  name  of  displacement  of  the  ovary,  and  the  cases  of  it 
which  have  come  under  my  notice  bear  out  the  accuracy  of  his 
description  ;  except  that  I  have  not  observed  the  paroxysms  of 
pain  to  have  anything  like  that  intensity  which  they  assumed  in 
some  of  his  cases. 

The  condition  seems  to  be  one  of  considerable  rarity,  for  I  have 
a  record  of  but  four  instances  of  its  occurrence,  though  I  have  seen 
a  few  other  cases  of  which  I  have  failed  to  preserve  an  account. 
The  patients  in  all  my  cases  were  married  women,  of  whom  the 
eldest  was  thirty-two,  the  youngest  twenty-three  years  of  age ;  but 
Dr.  Rigby  relates  an  instance  in  which  he  met  with  the  condition 
in  an  unmarried  girl  only  eighteen  years  old.  Two  of  my  patients 
were  sterile ;  the  other  two  had  given  birth  to  cljildren,  and  both 
of  these  latter  dated  their  symptoms  from  their  last  delivery.  In 
all  of  them  the  severe  pain  attendant  upon  sexual  intercourse  had 
b}'  degrees  compelled  its  discontinuance,  and  had  much  to  do  with 
the  application  of  tlie  patients  for  medical  aid.  Besides  this,  how- 
ever, there  were  complaints  of  pain  referred  to  the  lower  part  of 
the  abdomen,  though  severest  on  one  side,  aggravated  by  exer- 
tion, by  mefistruation,  often  induced  with  great  intensity  by  defe- 
cation, and  generally  being  severer  at  night  than  in  the  daytime, 
thus  preventing  sleep,  or  causing  the  rest  to  be  very  disturbed.  In 
one  patient  menstruation  was  natural,  except  that  it  was  attended 
by  unwonted  suffering;  but  in  the  otlier  three  the  discharge  was 
both  excessive  in  quantity,  and  anticipated  the  proper  period  of 
its  return.  Pressure  in  one  iliac  region  always  aggravated  the 
pain  f  but  the  paroxj^sms  of  sufl'ering  which  were  every  now  and 
then  superadded  to  the  abiding  discomfort,  and  which  were  at- 
tended by  a  sense  of  darting  and  shooting  referred  to  the  womb, 
lasting  sometimes  for  several  hours,  came  on  without  any  assign- 
able cause. 

These  s^miptoms  were  present  with  considerable  uniftu'mity  in 
all  the  cases,  and  in  all,  on  an  examination  per  vaginam,  there  was 
found  behind,  and  rather  to  one  side  of  the  uterus,  or  else  quite 
in  the  cul-de-sac  between  the  uterus  and  rectum,  an  oval  body, 
slightly  movable,  elastic,  intensely  tender  to  the  touch,  and  im- 

1  Medical  Times,  July  G,  1850. 


890  OVARIAN    DISPLACEMENT. 

mediately  recognized  by  the  patieut  as  the  point  whence  all  her 
suft'erings  proceeded. 

In  all  of  these  cases,  rest,  abstinence  from  sexual  intercourse, 
and  the  application  per  vaginam  of  leeches  to  the  neighborhood 
of  the  painful  part,  were  followed  by  the  gradual  cessation  of 
sutlering,  the  diminution  in  size  of  the  swollen  ovary,  and  the 
almost  complete  removal  of  the  tenderness.  In  no  instance,  how- 
ever, was  there  any  such  disappearance  of  the  tumor  felt  through 
the  roof  of  the  vagina  as  to  suggest  the  idea  that  the  main  element 
in  the  production  of  the  patient's  illness  had  been  the  displace- 
ment of  the  organ,  or  that  the  improvement  in  her  condition  was 
attributable  to  the  ovary  having  regained  its  natural  position. 

My  own  impression  is,  that  cases  of  this  kind  are  to  be  regai-ded 
as  instances  of  a  chronic  congestion  of  the  ovary  and  slow  increase 
of  its  size,  rather  than  as  illustrations  of  any  mere  change  in  the 
position  of  the  organ.  The  enlarged  ovary  almost  always  descends 
in  i\\e  pelvis,  and  in  the  early  stage  of  ovarian  dropsy  the  organ 
may  often  be  felt  per  vaginam  at  a  time  when  no  tumor  is  per- 
ceptible in  the  abdomen.  But  though  the  organ  may  by  growth 
thus  apparently  change  its  situation,  and  though  besides  its  liga- 
ment elongates  readily  enough,  as  we  see  in  cases  where  the  ovarian 
cyst  has  already  ascended  into  the  abdominal  cavity,  we  should 
yet,  I  think,  be  in  error  if  we  fancied  the  organ  so  loosely  tethered 
in  its  place  that  without  any  other  alteration  it  could  fall  down 
into  the  cul-de-sac  between  the  vagina  and  rectum,  and  be  made 
to  resume  its  proper  position  merely  by  the  patient  ])lacing  her- 
self in  a  prone  posture.  The  persistent  swelling,  which  in  my 
cases  remained  perceptible,  although  its  size  was  reduced  by  treat- 
ment, would  seem  to  me  to  indicate  that  inflammation  had  affected 
the  peritoneal  surface  of  the  ovary,  and  tied  it  down  behind  the 
womb  just  as  in  some  of  the  cases  which  I  referred  to  at  the  com- 
mencement of  this  Lecture.  The  subsidence  of  the  inflammation 
was  follow^ed  by  diminution  of  the  enlarged  ovary,  by  lessening 
of  its  exaggerated  sensibility,  but  not  by  its  return  to  its  previous 
position.  I  imagine,  too,  that  whatever  relief  a  patient  may  ex- 
perience in  these  cases  from  assuming  a  prone  position  may  iairly 
be  referred  to  the  removal  from  the  congested  and  tender  ovary 
of  the  weight  of  the  superincumbent  intestines,  to  which,  either 
in  the  sitting  or  in  the  recumbent  posture,  it  is  subjected.^ 

1  There  are  two  conditions  which  I  do  not  lii<e  to  pnss  over  entirely  without 
notice,  tliough  neither  of  them  has  come  under  my  own  observation.  One  of  them 
is  Hernia  oj  the  Ovary,  of  which  the  best  account  is  still  that  sjiven  by  Deneux,  in 
his  Recherches  sur  la  Hernie  de  VOvnrie,  8vo.,  Paris,  1813,  who  has  there  collected 
the  particulars  of  all  cases  recorded  down  to  the  time  of  the  publication  of  his 
essay.  The  compilers  of  the  Blbliothhque  du  Medecin-Praticien ;  Maladies  des 
Ftmmes,  vol.  i,p.  643,  have  a  long  article  on  the  subject,  for  which,  however,  they 
are  chiefly  indebted  to  Deneux  ;  while  Meissner's  laborious  work,  vol.  ii,  p.  240, 
contains  additional  references- to  cases  of  ovarian  displacements. 

The  other  atlection  is  one  for  our  knowledge  of  which  we  are  entirely  indebted 
to  M.  Huguier,  who  describes  in  the  Memoires  de  la  Societe  de  Chirurgie,  vol.  i,  1847, 
p.  295,  Serous  Cysts  on  the  exterior  of  the  uterus.  In  the  lecture  on  Cancer,  p.  284, 
I  described  productions  of  a  similar  kind  which  had  occasionally  come  under  my 


TUMORS  OF  THE  OVARY.  391 


LECTURE    XX  y. 

OVAKIAN  TUMORS  AND  DROPSY. 

Special  disposition  to  formation  of  cystic  growths  in  the  ovary. 

Varieties  of  cysts — the  simple  cysts;  cysts  of  the  Wolffian  bodies;  cysts  truly 

ovarian  :  their  relation  to  dropsy  of  the  Graafian  vesicles  ;  their  structure  and 

contents ;  modification  of  their  form  when  several  are  present.     Questions  as 

to  their  cause. 
Compound,    or   prolifkrous   cysts:    possible   development   from   simple   cj-sts. 

Structure  and  contents  of  comjiound  cysts,  and  of  cystosarcomatous  growths. 
Alveolar  or  colloid  growths  of  the  ovary. 

Cutaneous  or  fat  cysts:  their  peculiarities  of  structure  and  their  contents. 
Coni|)arative  frequency  of  affection  of  one  or  both  ovaries,  and  of  diU'erent  forms 

of  ovarian  tumor. 

I  HAVE  had  occasion  in  the  course  of  these  Lectures  to  make 
frequent  incidental  reference  to  enlargement  of  the  abdomen  aa 
an  attendant  upon  various  ailments  of  the  sexual  system ;  the 
consequence  and  one  of  the  signs  of  their  presence.  To-day,  how- 
ever, we  are  about  to  enter  on  the  examination  of  a  class  of  dis- 
eases whose  most  important  and  most  frequent  characteristic  is, 
that  they  bring  with  them  enlargement  of  the  abdomen, — that  this 
is  often  the  first  symptom  of  their  existence,  and  that  to  it  is  due 
no  small  share  of  the  patient's  sufferings. 

But,  while  they  have  this  one  s^maptom  in  common,  Tumors  of 
the  Ovaries  differ  most  widely  in  all  other  respects.  They  occnr  in 
the  young  and  the  aged,  in  the  single  and  in  the  married,  in  the 
sterile  and  in  women  who  have  given  birth  to  many  children. 

own  notice,  though  their  relation  appeared  to  be  somewhat  different  from  those  of 
the  cysts  of  which  M.  Huguier  speaks.  According  to  him,  they  are  sometimes 
developed  immediately  beneath  the  peritoneum  ;  at  other  times  in  the  sub-poritoneul 
cellular  tissue;  or,  lastly,  arc  subjacent  to  that  layer  of  fibro-cellular  tissue  which 
connects  the  serous  investment  of  the  ut(Tus  with  the  substance  of  the  organ. 
Their  most  frequent  seat  seems  to  be  the  posterior  surface  of  the  uterus,  since  they 
were  found  occupying  that  position  in  seven  out  of  thirteen  cases,  while  they  were 
situated  only  fuur  times  on  its  anterior  wall,  and  twice  on  its  fundus.  Though 
generally  sessile,  they  are  now  and  then  connected  with  the  uterus  by  a  narrow 
neck,  wiiich  sometimes  has  siirunk  to  a  slender  pedicle  of  cellular  tissue.  Their 
size  varies  from  that  of  a  millet-seed  to  the  bigness  of  an  egg,  or  eviMi  of  an  orange  ; 
and  the  larger  cysts  might,  especially  if  pediculated,  be  rcjadily  taken  for  cysts  of 
the  ovary.  The  diagnosis  between  the  two  would  seem,  indeed,  to  be  scarcely 
possible,  though  no  practical  evil  would  arise  from  an  error.  M.  Huguier  connects 
their  occurrence  with  previous  attacks  of  uterjne  congestion,  or  of  peritoneal  in- 
flammation; accidents,  iiowever,  wliich  are  so  common  in  comparison  with  tho 
cysts  to  which  they  are  supposed  to  give  rise,  that  tiicir  influence  must,  I  think,  bo 
regarded  as  very  doubtful.  The  sym|itoins  which  tliey  produce,  judgin;;  from  the 
two  cases  in  which  tiiey  were  discovered  during  tlie  ])atient's  life,  wi>uld  appear  to 
be  entirely  mechanical,  and  to  result  from  their  pressure  on  adjacent  organ*.  In 
one  instance  the  cyst  was  punctured  per  vaginiim;  about  ,^ij  of  trans])arent  serum 
were  evacuated,  and  the  cyst-wall  was  lightly  touched  witli  the  nitrate  of  silver. 
The  fluid  did  not  re-collect,  and  no  serious  symptom  followed  the  puncture. 

The  chief  importance  of  these  cysts  is,  perhaps,  from  their  introducing  a  new 
element  of  uncertainty  into  the  diagnosis  of  ovarian  tumor  in  an  early  stage. 


392  SIMPLE    OVARIAN    CYSTS. 

They  are  formed  sometimes  by  simple  cysts  containing  serous 
fluid,  at  other  times  they  are  composed  of  solid  matter,  while  in 
ver}"  many  instances  their  structure  is  identical  with  that  of  growths 
which  morbid  anatomists  have  unanimously  designated  malignant. 
Their  rate  of  increase  is  sometimes  quick,  at  other  times  slow,  and 
the  disease  which  liad  seemed  in  course  of  rapid  development 
becomes  occasionally  stationary,  and  so  remains  for  months  or 
years;  while  now  and  tlien  nature  herself  interferes,  and,  excel- 
ling all  that  the  most  skilful  physician  could  do,  completely  takes 
away  the  ill  wdiich  medicine  is  usually  impotent  to  cure.  Their 
diagnosis,  in  some  cases  most  easy,  is  in  others  attended  by  extreme 
difficulty ;  and  yet  there  are  scarcely  any  ailments  in  which  so  much 
is  involved  in  a  right  decision.  The  determination  that  the  sup- 
posed disease  is  in  reality  due  to  the  existence  of  pregnancy,  or 
that  the  suspected  pregnancy  is  but  the  evidence  of  disease,  often 
has  moral  consequences  which  touch  more  nearly  the  profoundest 
sources  of  human  happiness  or  misery  than  any  which  would  follow 
the  mere  assurance,  though  never  so  positive,  of  coming  health,  or 
the  admission  that  the  future  has  no  other  prospect  than  that  of  a 
lingering  and  painful  death.  The  prognosis  to  be  formed,  and  the 
treatment  to  be  adopted,*bring  with  them,  too,  their  own  peculiar 
difficulties.  Recovery,  when  there  seemed  small  ground  for  hope ; 
death,  when  little  had  appeared  to  call  for  apprehension ;  medical 
treatment  rejected  because  it  has  been  proved  inefficacious;  surgi- 
cal proceedings  shrunk  from  because  tliey  are  known  to  be  hazard- 
ous; additional  facts  scarcely  seeming  to  widen  our  experience,  or 
serving  only  to  detect  the  fallacy  of  some  loudly  vaunted  plan  of 
cure  :  such  are  the  uncertainties,  and  such  the  difficulties  that 
meet  us  when  we  propose  to  ourselves  the  inquiry — What  shall 
we  do  ?  In  short,  there  are  no  diseases  whose  pathology  is  more 
imperfect,  whose  symptoms  are  more  fluctuating,  whose  diagnosis 
is  more  obscure,  or  whose  treatment  is  founded  on  more  uncertain 
data  than  those  very  diseases  of  the  ovaries  which  are  yet  so  im- 
portant, and  to  whose  study  I  must  now  call  your  most  patient 
attention. 

In  each  of  the  different  organs  of  the  body  we  find  a  disposition 
more  or  less  marked  to  diseased  formation  similar  to  its  own  proper 
healthy  structure.  This  peculiarity  is  observable  in  tumors  of  bone, 
of  muscle,  of  nerve,  or  of  fibrous  tissue,  and  even  in  the  case  of 
those  formations  which,  from  their  non-identity  with  healthy 
structures,  have  received  the  name  of  heterologous,  something  of 
the  same  disposition  is  still  jierceptible.  Thus  the  cancerous 
tumor  of  bone,  while  interfering  with  and  destroying  the  structure 
of  the  part  in  which  it  is  formed,  is  yet  itself  built  up  upon  a 
bony  skeleton  or  fabric  ;  and  I  have  already  pointed  out  to  you 
how,  even  in  cancer  of  the  w*omb,  the  bulk  of  the  organ  is  increased, 
not  merely  by  the  morbid  deposit  in  its  substance,  but  also  by  the 
development  of  its  natural  structure. 

It  is  in  accordance  with  this  law  that,  in  the  ovary  especially 
(as  to  a  less  degree  in  all  glandular  organs,  such  as  the  thyroid 


CYSTS    OF    THE    AVOLFFIAN    BODIES.  893 

body,  the  testicle,  and  the  mamma),  there  exists  a  peculiar  liability 
to  cyst-formation  ;  and  that  nineteen  out  of  twenty  of  all  ovarian 
tumors  are  cystic  growths. 

Very  various  classifications  of  ovarian  cysts  have  been  proposed 
according  as  they  have  been  regarded  simply  from  a  practical  point 
of  view,  or  as  the  minuter  difierences  in  their  anatomical  structure 
have  also  been  taken  into  consideration.  It  is,  however,  so  desir- 
able to  avoid  multiplied  divisions  and  subdivisions,  that  I  propose 
to  conform  to  the  arrangement  adopted  by  Mr.  Paget,'  and  to 
speak  first  of  Simple  or  Barren  Cysts,  and  secondly,  of  Com- 
pound or  Proliferous  Cysts.  This  arrangement,  too,  will,  I  think, 
be  found  not  simply  anatomically  correct,  but  also  practically 
convenient. 

1^\\Q  first  kind  of  Simple  Cyst  is  one  which,  though  in  the  im- 
mediate vicinity  of  the  ovary,  is,  strictly  speaking,  not  connected 
with  it ;  but  which  I  mention  here  because  until  comparatively 
recently  its  nature  was  misapprehended,  and  erroneous  conclu- 
sions, based  on  this  misapprehension,  have  been  applied  to  real 
ovarian  cysts. 

In  examining  the  bodies  of  female  infants,  and  less  often  of 
female  adults,  w^e  may  sometimes  notice  hanging  from  the  under 
surface  of  the  Fallopian  tube,  nearer  to  its  fimbriated  than  to  its 
uterine  extremity,  small  delicate  cysts,  varying  in  size  from  the 
bigness  of  a  pea  to  that  of  a  cherry,  furnished  with  a  slender  pedicle 
from  one  to  three  inches  in  length,  and  containing  a  transparent, 
serous,  or  slightly  gelatinous  fluid.  Now  and  then  a  similar  cyst 
may  be  seen  bearing  the  same  relation  to  the  Fallopian  tube,  with 
the  exception  of  being  sessile  instead  of  pediculated.  Sometimes, 
too,  a  cyst  of  larger  size  may  be  observed  within  the  folds  of  the 
broad  ligament  situated  between  the  ovary  and  the  Fallopian  tube, 
but  obviously  not  originating  in  either;  and  the  cysts  of  this  latter 
kind,  unlike  the  others,  are  observed  in  the  grown  subject.  The 
diiference  of  their  seat  seems  to  be  the  only  point  of  dissimilarity 
between  them,  for  the  wall  of  both  is  composed  of  a  thin,  structure- 
less membrane,  incapable  of  division  into  layers,  often,  though  by 
no  means  constantly,  furnished  with  a  lining  of  nucleated  epithe- 
lium ;  while  their  contents,  though  usually  serous  and  colorless, 
are  sometimes  reddish  and  gelatinous. 

The  delicacy  of  the  cyst-wall,  the  absence  of  any  support,  and 
the  slcnderness  of  its  foot-stalk,  are  doubtless,  as  has  been  sug- 
gested by  M.  Verneuil,'  the  reasons  why  the  pendent  variety  of 
cyst  is  seldom  met  with  after  early  infancy,  while  tlie  support 
which  the  peritoneum  on  either  side  furnishes  to  the  sessile  cyst 

1  Surcjical  Paihology,  vol.  ii,  p.  26. 

2  By  far  the  best  account  of  these  cysts,  which  contains  also  a' notice  of  the  ob- 
servations of  previous  writers,  is  tiiat  of  Dr.  "\'erneuil,  Rrclierchcs  sur  tes  Kt/xfes  de 
l'07\rjinir  de  Wolff,  Mhyioires  de  In  Sociele  de  C7iii"iir</ie,  1854,  vol.  iv,  p.  AS.  Virehow, 
who  gives  (Die  Krankhaften  Oesr/iviilfiie,  vol.  i,  p.  2f>2)  an  account  of  these  small 
cysts,  demurs  to  the  correctness  of  this  hypothesis,  and  believes  them  to  be  usually, 
if  nut  invariably,  new  formations.  * 


394  CYSTS    OF    THE    WOLFFIAN    BODIES. 

which  is  situated  between  the  folds  of  the  broad  ligament,  allows 
of  its  readier  enlargement  and  of  its  attainment  of  a  greater  size. 
An  examination  of  the  pedicle  of  those  cysts  which  hang  from  the 
Fallopian  tube  furnishes  the  clue  to  the  understanding  of  the  real 
nature  of  these  growths.  This  pedicle  is  often  found  to  be  hollow, 
though  in  the  course  of  its  gradual  elongation  and  attenuation  it 
becomes  converted  into  a  slender  cord.  The  canal,  however,  some- 
times even  communicating  with  the  cj^st,  points  to  its  origin  in  the 
dihitation  of  one  of  the  small  ci^cal  tubes  which  make  up  the 
"Wolffian  bodies  in  the  fcetus,  and  the  slight  remains  of  which, 
difficultly  discernible  in  the  adult,  have  received  from  their  de- 
scriber  the  name  of  the  Corpus  Rosenmlilleri. 

The  size  of  an  egg,  an  apple,  or  an  orange,  is  the  greatest  magni- 
tude to  which  these  cysts  have  yet  been  proved  to  attain;  and  the 
pendent  cysts  very  rarely  indeed  reach  dimensions  sufficient  to 
make  them  recognizable  during  life.  With  the  exception,  too,  of 
the  giving  way  of  the  pedicle  of  the  pendent  cysts,  and  the  prob- 
able rupture  of  the  delicate  walls  of  both  kinds  of  these  growths, 
there  are  no  changes  which  have  been  observed  to  take  place  in 
them ;  and  in  no  instance  has  cyst  formation  occurred  in  their 
walls  or  into  their  cavity,  though  several  distinct  cysts,  especially 
of  the  pediculated  kind,  are  by  no  means  infrequently  seen  in  the 
same  su Inject. 

Before  proceeding  to  examine  the  other  and  more  important 
cysts  wliich  really  spring  from  the  ovary  itself,  we  must  for  a 
moment  nf)tice  a  circumstance  which  has  given  to  these  cj'sts  of 
the  broad  ligament,  as  they  have  generally  been  termed,  a  greater 
pathological  value  than  really  attaches  to  them.  It  has  been  very 
customary  for  medical  men,  whenever  they  met  with  a  simple  cyst 
tolerably  movable,  and  of  moderate  size,  to  assume  that  such  a  cyst 
was  not  ovarian,  and  to  console  their  patients  with  the  assurance 
that  it  is  a  less  serious  disease,  and  one  much  less  likely  to  in- 
crease. Now,  while  it  is  of  great  moment  to  give  to  our  patients 
every  legitimate  comfort,  and  to  encourage  all  reasonable  ho[)e,  it 
is  yet  no  less  important,  in  the  interests  alike  of  science  and  of 
humanity,  that  we  should  not  make  large  promises  or  give  posi- 
tive assurances  w'ithout  aderpiate  grounds.  A  visit  to  any  of  the 
large  museums  of  this  metropolis  will  suffice  to  convince  any  one 
that  cysts  of  the  Wolffian  bodies  of  size  sufficient  to  be  distin- 
guishable during  life  are  of  very  great  rarity,  while  the  same  evi- 
dence will  also  prove  that  for  such  cysts  to  exceed  the  dimensions 
of  an  apple  is  rarer  still.  Whenever  then  a  tumor  is  discovered 
in  the  abdomen  which  has  attained  a  greater  size  than  that  of  the 
doubled  fist,  that  circumstance  may  be  taken  as  in  itself  affording 
almost  conclusive  proof  that  the  cyst  is  not  extra-ovarian,  nor  of 
that  kind  concerning  which  it  can  be  foretold  that  its  tendency 
will  be  to  remain  stationary,  rather  than  to  increase  in  size. 

But  we  may  now  pass  to  the  study  of  those  various  kinds  of 
cysts  and  cystoid  growths  which  have  their  origin  in  the  ovary  itself. 

The  simplest  of  these,  the  least  dangerous — I  fear,  however,  by 


SIMPLE    CYSTS    OF    THE    OVARY    ITSELF.  395 

no  means  the  most  frequent — are  those  which  are  produced  by 
the  dropsy,  or  over-disteusion  with  fluid,  of  one  or  more  G-raafian 
vesicles. 

The  structure  of  these  simple  ovarian  cysts  plainly  indicates 
their  orii^in.  They  are  furnished  with  three  coats:  the  first,  the 
peritoneal  investment  of  the  ovary;  the  next,  the  capsule  of  the 
organ,  on  whose  surface  ramify  the  vessels  that  supply  it;  and  the 
third,  the  wall  of  the  Graafian  vesicle  itself,  which  is  usually  much 
thickened,  generally  divisible  into  several  layers,  and  has  a  lining 
of  tessellated  epithelium.  This  laminated  structure  of  the  ovarian 
cyst  is,  as  we  shall  hereafter  see,  not  without  its  practical  import- 
ance, inasmuch  as  it  sometimes  increases  the  ditficulties  of  the 
operator,  who  cannot,  if  adhesion  exist,  always  distinguish  read- 
ily whether  his  finger  is  breaking  down  the  connections  between 
the  enlarged  ovary  and  the  peritoneum,  or  whether  it  is  separating 
the  layers  of  the  cyst- wall. 

The  surface  of  these  cysts  is  generally  white  and  glistening,  and 
their  interior  smooth  and  polished;  sometimes  of"  a  dead  white 
color,  or  even  of  a  mother-of pearl  lustre;  unless  the  growth  has 
been  the  seat  of  inflammation,  when  it  will  in  many  parts  he  dull, 
roughened  on  its  interior  by  old  deposits  of  lymph,  and  its  walls 
will  be  found  to  present  various  degrees  of  firmnes^s,  density,  and 
thickness.  Even  independently  of  previous  inflammation  the 
thickness  of  the  cyst-wall  often  varies  at  dift'erent  parts,  and  is 
by  no  ineiins  most  considerable  in  all  cases  close  to  the  pedicle  of 
the  growth. 

The  vessels  of  these,  as  indeed  of  all  ovarian  cysts,  are  usually 
of  considerable  size  ;  while  their  distribution  is  uncertain  beyond 
the  fact  that  all  converge  towards  the  pedicle  of  the  cyst.  They 
almost  all  present  a  venous  character,  or,  as  Cruveilhier  aptly 
says,  in  describing  the  structure  of  a  large  ovarian  cyst,'  '"They 
are  venous  sinuses  analogous  to  those  of  the  dura  mater,"  and, 
ramifying  immediately  beneath  the  peritonetim,  their  delicate 
outer  wall  seems  wholly  formed  by  that  membrane.  The  large 
size  of  these  superficial  veins  is  to  be  borne  in  mind  as  an  occa- 
sional source  of  danger  in  tapping;  while  their  convergence 
towards  the  pedicle  of  the  tumor  constitutes  one  of  the  principal 
objections  to  the  operation  of  ta[)ping  [tcr  vaginam.  The  branches 
which  pass  from  these  trunks  towards  the  interior  of  the  cyst,  and 
which  ramify,  sometimes  very  abundantly,  on  its  inner  wall,  are 
small  in  size,  but  still  retain  their  venous  character,  and  this  pre- 
ponderance of  the  venous  over  the  arterial  system  is  the  groat 
peculiarity  of  the  vascular  supply  of  these  growths. 

Be  their  size  what  it  may  (and  this  is  liable  to  very  wide  varia- 
tions; for  while  sometimes  no  larger  than  a  pea,  they  contain  in 
other  cases  a  gallon  or  a  gallon  and  a  halt  of  fluid)  their  contents 
are  usually  of  the  same  description — namely,  serum,  often  of  a 
rather  low  specific  gravity,  and  very  seldom  exceeding  lOiiO,  highly 

'  Anatomic  PaUiologique  Generale,  8vo.,  Paris,  185G,  vol.  iii,  p.  408. 


396  STRUCTURE    OF 

albuminous,  of  a  slightly  greenish  color,  and  though  generally  trans- 
parent, yet  occasionally  more  or  less  stained  with  blood.  Some- 
times, indeed,  the  fluid  contains  a  large  admixture  of  pus,  and  now 
and  then  presents  characters  but  little  distinguishable  from  those 
of  healthy  matter.  This,  too,  may  be  the  case  even  when  few  local 
symptoms  of  inflammation  have  been  present,  so  that  it  is  not 
possible  to  foretell  with  any  certainty  the  nattire  of  the  fluid 
which  even  a  simple  ovarian  cyst  may  be  found  to  contain ;  or  to 
infer  the  absence  of  inflammation  from  the  absence  of  pain.  The 
circumstance  which  imparts  to  this  fact  its  practical  importance 
is  that  inflammation  of  the  interior  of  the  cyst  is  in  very  many 
instances  accompanied  by  inflammation  of  its  peritoneal  surface, 
of  extent  and  intensity  suflicient  to  produce  very  considerable  ad- 
hesions with  adjacent  viscera,  while  even  this  peritonitis  may  give 
rise  to  no  severe  pain.  The  feasibility  of  various  surgical  proceed- 
ings for  the  cure  of  ovarian  dropsy  depends  to  a  great  degree  on 
the  absence  of  adhesions.  The  want  of  any  certain  means  by 
which  to  determine  their  presence  or  absence  is  one  of  the  most 
serious  of  the  difliculties  that  beset  all  operations  for  the  extirpa- 
tion of  diseased  ovaries. 

I  have  described  this  affection  hitherto  as  it  presents  itself  to 
our  notice  when  confined  to  a  single  Graafian  vesicle.  It  is,  how- 
ever, seldom  that  the  disease  is  so  strictly  limited,  but  usually 
other  vesicles,  sometimes  in  both  ovaries,  show  a  disposition  to 
the  same  dropsical  condition.  Not  infrequently,  too,  we  meet 
with  cases  in  which  the  affection  of  several  vesicles  has  appeared 
to  have  commenced  simultaneously,  all  being  equally  enlarged; 
and  the  ovary  containing  as  many  perhaps  as  ten  or  fifteen  small 
cysts  no  bigger  possibly  than  a  large  pea.  As  these  cysts  increase 
in  size,  they  lose  by  their  mutual  pressure  the  regularly  globular 
form  which  at  first  they  present,  becoming  flattened,  or  somewhat 
wedge-shaped,  with  their  broader  end  outwards.  When,  however, 
the  ovary  has  attained  to  dimensions  greater  than  those  of  an  un- 
shelled  walnut,  or  of  an  egg,  the  development  of  one  or  two  of  the 
cysts  generally  goes  on  at  tlie  expense  of  the  others,  and  a  multi- 
locular  tumor  is  thus  produced,  made  up  of  a  number  of  simple 
cysts,  of  very  various  sizes,  from  that  of  the  adult  head  to  that  of 
an  apple  or  an  orange.  The  contents  of  these  cysts,  too,  may  vary 
as  much  as  their  size,  for  while  some  are  filled  with  transparent 
serum,  others  may  contain  fluid  deeply  tinged  with  blood,  and 
others  again  a  sero-purulent  secretion,  according  as  hemorrhage 
or  inflammation  has  occurred  in  one  and  has  not  occurred  in  an- 
other, even  though  immediately  adjacent.  These  varieties  in  the 
same  tumor  have  sometimes  given  occasion  to  the  opinion  that  a 
growth  is  a  compound  cyst,  when  in  reality  it  is  only  an  aggrega- 
tion of  simple  cysts  in  which  morbid  processes  of  various  kinds 
have  been  going  on.  It  is  by  no  means  an  unusual  occurrence, 
too,  with  tumors  of  this  description,  for  their  pressure  on  each 
other  to  produce  absorption  of  the  dividing  septa,  and  for  a  multi- 
locular  tumor  to  be  thus  in  the  course  of  time  converted  into  a 


SIMPLE    OVARIAN    CYSTS.  397 

single  cyst.  The  openings  of  communication  between  the  dif- 
ferent cysts  are  usually  of  a  circular  form,  with  smooth  edges,  as 
if  a  portion  of  the  wall  had  been  removed  by  some  cutting  instru- 
ment, and  while  small  at  first,  the  advance  of  the  process  of  ab- 
sorption by  degrees  enlarges  them ;  till  at  length  a  slight  irregu- 
larity in  the  external  contour  of  the  tumor  remains  as  the  only 
Bvidence  of  its  original  structure.  The  circumstances  that  regulate 
the  process  are,  however,  by  no  means  clearly  understood ;  for 
tvliile  the  absorption  of  the  septa  sometimes  takes  place  at  a  time 
ivhen  none  of  the  cysts  are  larger  than  a  marble,  it  is  far  from 
unusual  to  find  the  partitions  still  entire  when  some  of  the  cysts 
tiave  reached  the  size  of  the  adult  head,  or  have  even  attained 
still  larger  dimensions. 

It  is  perhaps  needless  to  say  that  dropsical  enlargement  of  the 
Graafian  vesicles  is  by  no  means  the  only  source  whence  simple 
Dvarian  cysts  may  be  produced.  There  can  indeed  be  no  doubt 
^ut  that  tlie  development  of  cysts  may  go  on  in  the  ovary  just  as  it 
iocs  sometimes  in  the  kidney,  not  by  any  enlargement  of  pre- 
existing cavities,  but  by  a  process  which  is  one  of  new  formation 
irom  the  very  beginning.  Still  the  whole  tendency  of  pathological 
'esearch  is  to  increase  the  number  of  instances  in  which  cysts  are 
brmud  by  the  enlargement  of  pre-existing  cavities ;  and  besides, 
;lie  question  has  been  set  at  rest  as  far  as  the  occasional  production 
)f  ovarian  dropsy  from  enlarged  Graafian  vesicles  is  concerned  by 
[lokitansky's  discovery  of  the  ovule  within  the  cyst  in  a  case  of 
ncipient  cystic  disease  of  the  ovary.^ 

The  precise  mode  in  which  the  dropsical  condition  of  the  vesicles 
s  produced,  is  indeed,  and  probably  will  always  renuiin,  to  a  great 
iegree  unknown.  It  seems,  however,  to  be  very  likely  that  in 
lome  cases  at  least  a  state  of  congestion  of  the  vesicle,  and  hemor- 
•hage  into  its  cavity,  are  the  first  steps  towards  the  production  of 
he  subsequent  efiusion.  In  the  museum  of  Guy's  Hospital,  to 
vhich  I  was  most  courteously  admitted,  are  a  series  of  prepara- 
ions  which  appear  to  illustrate  this  mode  of  origin  of  ovarian 
Iropsy.  In  some  of  them  a  clot  alone  is  seen  within  the  vesicle ; 
n  others  the  clot  occupies  only  a  portion  of  the  cyst,  adhering  to 
ts  wall  by  a  sort  of  pedicle,  while  the  remainder  of  the  cavity  is 
)ccupied  by  a  serous  fluid;  the  relative  proportions  of  the  clot  and 
he  fluid  varying  much  in  difl'erent  specimens.  Now,  just  as 
lemorrhage  into  the  sac  of  the  arachnoid  is  followed  in  many  iu- 

^  ir/ewer  WocJicnhlatt,  1855,  No.  1,  as  quotod  by  Scanzoni,  Lchrhuch  der  Krnnk- 
'^iteu  dei-  Weiblichen  Sexual  Organe,  8vo.,  Wicn,  1857,  p.  354.  See  also  Virchow, 
)ie  Krankhaften  Geschwiilste,  vol.  i,  p.  259.  The  question  is  one  of  so  much 
nomcnt  with  rctbrcnce  to  the  prognosis  of  ovarian  dropsy,  and  the  ojiiniou  of  so 
ligh  iin  authority  as  Dr.  Bright  (see  Guy's  Hospital  RcportH,  vol.  iii,  1838,  pp.  181 
nd  193)  is  so  decidedly  unfavorable,  that  one  rejoices  at  obtaining  any  evidence 
phich  enables  us  to  soften  the  very  dark  hues  of  the  picture  wiiich  he  has  drawn. 
'Tliis  ease,"  says  he,  loc.  cii.,  p.  193,  "  adds  to  the  doubt  I  have  already  expressed 
if  having  met  witli  any  very  distinct  case  of  dropsical  accumulation  in  the  Graa- 
ian  vesicles,  as  distinguished  from  the  disease  which  runs  into  the  malignant 
ivarian  tumor." 


398  COMPOUND    OVARIAN    CYSTS. 

stances  by  the  subsequent  effusion  of  serum  so  far  exceeding  in 
quantity  that  of  the  blood  originally  extravasated,  as  to  produce 
one  form  of  chronic  hydrocephalus,  so  tliere  can  be  no  reason  for 
doubting  but  that  hemorrhage  into  the  sac  of  a  Graafian  vesicle 
may  in  like  manner  be  followed  by  a  similar  hypersecretion. 

A  theory,  indeed,  has  been  propounded,  the  very  opposite  of 
this,  by  Professor  Scanzoni,'  who  suggests  that  the  dropsical  con- 
dition of  the  Graafian  vesicle  may  be  due  to  the  flow  of  blood  to 
the  ovary  at  a  menstrual  period  having  been  insufficient  to  produce 
the  rupture  of  the  sac  and  the  escape  of  an  ovule,  but  sufficient 
only  to  occasion  a  certain  degree  of  congestion,  terminating  in  an 
increased  effusion  of  fluid  into  its  cavity.  This  theory  is  based 
chiefly  on  the  alleged  frequency  of  amenorrhoea,  or  of  scanty  men- 
struation, as  a  precursor  of  ovarian  dropsy;  an  allegation  which, 
as  we  shall  see  hereafter,  is  scarcely  substantiated. 

I  know  of  no  other  facts,  nor  of  any  other  plausible  theory 
bearing  on  the  production  of  dropsy  of  the  Graafian  vesicles;  and 
I  fear  that  I  must  confess  my  inability  to  determine  the  proportion 
of  instances  in  which  simple  cysts  of  the  ovary  are  due  to  the 
enlargement  of  these  cavities,  and  of  those  in  which  the  cysts  are 
tliemselves  of  new  formation.  That  simple  cysts  may  arise  here, 
however,  as  in  other  parts,  by  the  mere  collection  of  fluid  in  the 
parenchyma  of  the  organ,  and  the  gradual  formation  of  a  cyst 
around  it,  I  see  no  reason  to  doubt.^  Possibly  some  of  the  very 
delicate  and  thin-wallcd  ovarian  cysts  which  we  occasionally  meet 
with  may  have  this  origin ;  but  my  conviction  is,  that  this  is  not 
the  general  mode  of  production  of  simple  cysts,  but  that  most  are 
formed  l)y  the  distension  of  a  pre-existent  cavity. 

Another  question  of  greater  practical  moment  is  w-hether  single 
cysts  always  remain  single,  or  whether  they  may  not  become  pro- 
liferous or  compound  cysts  in  the  course  of  their  development. 
Here,  too,  it  is  to  be  regretted  that  our  data  do  not  suiflce  for  a 
satisfactory  answer  to  this  inquiry.  The  practical  consequences 
involved  in  the  decision  of  this  point  are  very  obvious;  for  it  is 
apparent  that  if  at  any  period  a  simple  cyst  is  capable  of  passing 
into  an  active  state,  and  of  enlarging  not  by  mere  distension  of  its 
cavity,  but  by  growth  in  its  interior,  or  by  cyst-formation  in  its 
walls,  the  ex[)ediency  of  having  recourse  to  early  and  very  decided 
therapeutical  proceedings  becomes  far  greater  than  it  otherwise 
would  be.  My  belief  is,  that  such  a  change  may  take  place,  and 
that  a  cj'st  originally  barren  may  become  pi'oliferous;  that  its  con- 
tinuing simple  is  rather  a  happy  accident  than  a  condition  on  the 
permanence  of  which  we  can  calculate  with  any  certainty.  A 
3'oung  woman  who  had  been  the  subject  of  ovarian  dropsy  for  two 
years  and  a  half,  and  who  had  been*  tapped  a  year  before  her  death, 
sank  under  the  effects  of  peritoneal  inflammation  induced  by  an 

1  Op.  cit,  p.  353. 

'  A  mode  of  cyst-procluction  most  fully  illustrated  by  Professor  Bruch,  Ziir  Ent- 
vneklmigs-geschichte der  PathoLogischen  Cystenbildungen,  in  Zeiischr.f.  RationtUe  Med- 
izi7i,  vol.  viii,  1849,  p.  91. 


COMPOUND    OVARIAN    CYSTS.  399 

attempt  to  inject  the  cjst  with  iodine.  The  cyst  was  found  to  be 
a  tliiii  walled  simple  cyst,  but  at  one  point,  near  to  the  pedicle  of 
tlie  growth,  four  little  cysts,  the  largest  of  which  was  about  the 
size  of  u  bean,  projected  from  its  internal  surface,  and  round  this 
group  the  lining  itself  was  more  vascular  and  rather  softer  than 
elsewhere.  Larger  opportunities  than  I  have  ever  possessed  of 
making  examinations  alter  death,  would,  I  doubt  not,  have  fur- 
nished me  wnth  other  illustrations  of  a  fact  which  is  entirely  in 
accordance  with  the  result  to  wliich  analogical  reasoning  wcnild 
lead  us.  Without  the  stimulus  of  impregnation,  a  Graafian  vesicle 
does,  we  know,  sometimes  produce  hair,  fat,  teeth,  cartilage,  and 
bone,  and  the  proliferous  power  of  which  these  are  the  highest 
instances,  may  also,  without  doubt,  exert  itself  in  lower  fcJVms  in 
the  production  of  endogenous  growths  in  its  interior;  and,  though 
possibly  less  often,  in  exogenous  cell-formation  from  its  walls. 

In  some  of  the  cases  of  endogenous  cell  develojunent,  the 
growths  that  occupy  the  interior  of  the  cyst  spring  universally 
from  its  walls,  and  consist  of  an  immense  number  of  small  ped- 
unculated cysts  or  vesicles,  multiplied  apparently  by  the  same 
simple  process  of  growth  as  has  been  so  well  studied  in  the 
hydatid  disease  of  the  chorion.  Such  growths  may,  too,  be  so 
numerous  as  to  fill  nearly  the  whole  of  the  interior  ol  a  very  large 
cyst.^  In  other  cases  the  endogenous  growth,  though  similar  in 
its  character,  does  not  arise  from  the  whole  of  the  interior  of  the 
cyst,  but  is  connected  with  it  by  a  pedicle,  from  which  a  pyriform 
mass  of  cystic  growths  proceeds. 

Be-^ides  these  forms  of  endogenous  growth,  there  is  another  in 
which  the  cavity  of  the  parent  cyst  is  more  or  less  completely 
occupied  by  others  of  a  smaller  size,  but  springing  from  it  by  a 
broad  base,^  and  containing  within  thehiselves  others  of  a  third 
order,  of  smaller  size,  and  with  thinner  walls.  As  these  cysts 
grow,  some  probably  empty  themselves  completely  into  the  parent 
cyst,  and,  collapsing,  become  adherent  to  its  walls,  thus  gi\  ing  to 
them  that  thickness  and  resistance  which  in  some  cases,  even  of 
large  ovaiian  cysts,  are  very  remarkable.  At  the  same  time  the 
progressive  increase  of  the  smaller  cysts,  and  the  constant  forma- 
tion of  new  cysts,  help  to  make  up  that  enormous  mass  to  which 
ovarian  tumors  sometimes  attain. 

I>ut  while  there  is  perhaps  room  for  doubt  as  to  the  nature  of 
the  original  growth  whence  these  forms  of  complex  cysts  arise, 
there  can  be  no  question  but  that  some  cysts  assume  the  complex 
character  from  their  very  commencement,  and  are  not  developed 
out  of  any  transformation  of  the  Graafian  vesicles.  In  these  cases 
we  find  the  ovary  converted  into  a  tumor  of  irregular  form  ;  its 
firm,  fibrous  capsule,  some  quarter  or  third  of  an  inch  in  tliickness, 
inclosing  a  number  of  cysts  or  cells,  one  or  two  of  whieh  nuiy 
greatly  exceed  the  dimensions  of  the  others,  and  be  capable  of 

1  As  in  a  very  remarkahlo  preparation,  No.  224j"  in  Guj-'s  Hospital  Museum. 
*  As  No.  2622  in  the  llunterian  Museum. 


400  COMPOUND    OVARIAN    CYSTS. 

containing  many  quarts  of  fluid,  while  the  remainder  vary  in  size 
from  the  bigness  of  a  marble  to  that  of  a  pigeon's  egg,  or  an  apple. 
While  some  of  them  may  appear  as  separated  cysts,  adherent  to 
the  others,  but  apparently  developed  independently  of  them, 
others  have  obviously  been  formed  in  the  thickness  of  the  cyst- 
wall  itself,  and  project,  sometimes  inwards,  at  other  times  towards 
its  exterior.  When  the  growths  have  attained  to  any  considerable 
size,  inflammation  generally  roughens  their  originally  smooth  in- 
ternal membrane,  and  deposits  of  lymph  thicken  it;  or  the  col- 
lapse of  some  of  the  smaller  cysts,  and  their  incorporation  with 
the  dividing  walls  of  the  difl'erent  cavities,  thicken  as  well  as 
otherwise  alter  the  septa.  At  the  same  time,  too,  similar  causes 
modity  their  contents,  so  that  while  one  cyst  is  filled  with  a  serous 
fluid,  another  contains  a  glairy,  albuminous  matter,  or  its  contents 
are  deeply  tinged  with  blood,  or  are  of  a  dark  chocolate  color; 
while  others  contain  pus,  or  sero-purulent  fluid,  or  a  liquid  in 
which  scales  of  cholesterine  sparkle  like  the  brilliant  particles  in 
Dantzic  eau  de  vie.  It  is  usually  towards  the  pedicle  of  these 
tumors,  where  the  smaller  cysts  are  mostly  situated,  that  their 
structure  can  be  best  studied.  They  are  then  seen  to  be  formed 
by  a  smooth,  polished  membrane,  tough  and  resistant,  though 
thin,  scared}'  semi-transparent,  but  of  a  white  color,  and  su[>plied 
by  long  slender  bloodvessels,  which  ramity  on  their  outer  surface. 
Their  general  form  is  oval,  but  as  they  increase  in  size  this  is  much 
modified  by  their  mutual  pressure  on  each  other;  while  besides, 
irregular  spaces  exist  here  and  there,  partly  produced,  perhaps, 
by  the  I'usion  of  two  or  more  cysts  together,  partly  by  the  inter- 
vals left  between  several  adjacent  cysts.  The  smaller  size  of  the 
cysts  near  the  pedicle  of  the  tumor  is  apparently  due  to  their 
being  subjected  to  a  grealfcr  degree  of  compression  than  the  others, 
for  sometimes  a  large  cyst  will  develop  itself  downwards  into  the 
pelvic  cavity;  while  again,  where  the  increase  of  the  tumor  has 
been  very  rapid,  a  number  of  small  cysts  may  sometimes  be  Ibund 
towards  its  upper  part,  where  apparently  the  resistance  oftered  by 
the  transverse  colon,  the  liver,  stomach,  and  diaphragm,  has  also 
prevented  their  increase.^ 

The  amount  of  solid  matter  which  enters  into  the  composition 
of  these  cystic  tumors  of  the  ovary  varies  exceedingly.  In  many 
cases,  as  in  those  just  described,  the  whole  mass  is  but  a  collection 
of  cysts,  whose  walls,  even  when  thickest,  bear  but  a  small  propor- 
tion to  the  quantity  of  fluid  which  their  cavities  contain.  In  other 
instances,  however,  these  proportions  are  reversed,  and  the  bulk 
of  the  solid  matter  far  exceeds  that  of  the  fluid.  This  is  the  kind 
of  tumor  to  which  the  name  of  cystosarcovia  has  been  applied  by 
MiJller,'^  who  describes  it  as  principally  composed  of  a  more  or  less 
firm,  fibrous,  or  vascular  mass,  but  invariably  containing  solitary 
cysts  in  its  substance.     The  fibrous  masses  consist  of  an  albumin- 

'  A  very  good  drawing  of  a  compound  ovarian  cyst  given  by  Dr.  Bright,  f>j^.  cit., 
pi.  V,  p.  276. 

*  On  Cancer,  &c.,  English  translation,  London,  8vo.,  1840,  p.  170. 


COLLOID    TUMORS.  401 

ous  substance,  and  sometimes  contain  granules  scattered  between 
their  fibrils,  and  the  fibrous  tissue  forms  the  stroma  in  wliich  the 
separate  cysts  are  imbedded. 

1  do  not  feel  myself  competent  to  decide  how  far  these  growths 
really  require  to  be  referred  to  a  separate  category.  The  structure 
of  the  cysts,  and  their  various  contents,  are  analogous  to  what  one 
observes  in  other  compound  ovarian  cysts.  Perhaps,  however,  it 
should  be  added  that  fat-cysts,  or  cysts  containing  hair,  teeth,  or 
other  products  of  cutaneous  tissues,  when  not  existing  alone,  are 
most  frequently  associated  with  cystosarcoma ;  and,  further,  that 
these  comparatively  solid  growths  do  not  attain  to  the  enormous 
dimensions  of  other  compound  ovarian  cysts,  and  very  seldom 
exceed  the  size  of  the  adult  head. 

Another  form  of  compou^td  ovarian  cynt^  allied  to  the  preceding 
kinds,  but  I  believe  essentially  difi'erent  from  them,  is  that  in 
which  the  organ  is  the  seat  of  alveolar  or  colloid  cancer,  a  disease* 
whose  precise  relations  to  other  varieties  of  carcinoma  are  as  yet 
undetermined.  The  grand  characteristic  of  colloid  degeneration 
of  any  part  is,  as  you  know,  the  development  in  its  substance  of 
innumerable  cells,  containing  a  tenacious,  gummy  secretion,  which 
vary  from  a  size  too  small  to  be  discerned  by  the  naked  eye,  to  an 
inch  or  rather  more  than  an  inch  in  diameter.  These  cells  in- 
crease, though  by  no  means  exclusively,  by  endogenous  growth, 
and  the  presence  of  a  countless  number  in  the  same  stage  of 
development  shows  that  the  formation  of  very  many  occurs  si- 
multaneously. If  their  contents  are  washed  out  so  as  to  leave  be- 
hind only  a  skeleton  of  the  growth,  it  is  then  perceived  that  very 
many  of  the  cells  or  sacculi  communicate  with  each  other;  the 
whole  mass  having  a  honeycombed  appearance,  or  resembling, 
perhaps,  more  closely  a  section  of  the  lung  of  a  reptile.  The 
septa  between  the  cells  are  in  general  of  a  somewhat  firm,  though 
delicate  fibrous  tissue,  of  a  whitish,  sometimes  of  a  dead-white 
color;  though  while  the  cells  are  very  minute,  their  walls,  or  the 
septa  between  the  areolae,  are  semi-transparent,  and  their  jelly-like 
contents  shining  through,  they  look  not  unlike  grains  of  boiled 
sago. 

In  the  ovaries  this  colloid  disease  assumes  many  diferent  forms. 
Sometimes  several  rounded  masses  make  up  an  irregular  tumor, 
which  is  solid  to  the  touch,  and  firm  on  section,  presenting  no 
trace  of  the  proper  tissue  of  the  part,  but  a  structureless  substance 
in  which  are  imbedded  countless  semi-transparent  grayish  cells, 
scarcely  any  of  which  are  larger  than  the  head  of  a  large  pin. 
Again,  in  other  cases  the  cell-walls  generally  are  very  delicate, 
while  large  spaces  are  left  between,  of  irregular  form,  and  filled 
with  the  characteristic  gelatinous  secretion,  whicli  may  be  col- 
lected to  the  amount  of  several  ounces  or  of  a  pint,  or  more.    iSuch 

1  A  good  representation  of  alveolar  cancer  of  the  ovary  is  given  by  Cruvoilhier, 
Atlas,  &c.,  livr.  v,  pi.  3. 

26 


402  COLLOID    TUMORS. 

spaces,  however,  do  not  appear  to  be  cysts  enlarged  beyond  the 
dimensions  of  those  which  surround  them,  but  to  be  mere  inter- 
spaces of  irregular  form  produced  by  the  absorption  or  liquefac- 
tion of  the  cell-walls,  and  the  consequent  escape  of  their  contents 
into  a  common  receptacle.^ 

Besides  the  instances  in  which  colloid  disease  exists  alone,  cases 
are  by  no  means  unusual  of  its  association  either  with  compound 
cysts  of  the  ovary,  or  with  fungoid  or  medullary  cancer  of  the 
organ.  In  the  former  case  it  is  far  from  uncommon  for  one  or  two 
of  the  cysts  to  have  attained  to  a  very  great  magnitude  ;  and  the 
colloid  matter  may  be  in  part  poured  into  them  from  some  of  the 
adjacent  cells,  so  as  to  give  to  their  contents  almost  the  same  de- 
gree of  tenacity  as  is  observed  in  the  secretion  within  the  small 
cells  of  alveolar  cancer.  Even  though  this  should  be  the  case, 
however,  and  though  there  should  be  very  close  juxtaposition  of 
the  two  structures,  the  differences  between  them  will,  I  think,  be 
sufficiently  obvious. 

In  the  case  of  the  association  of  genuine  fungoid  cancer  with 
the  colloid  disease,  it  is  usually  about  the  pedicle  of  the  tumor, 
and  near  its  base,  that  the  great  mass  of  cancer  is  situated.  It  is 
not,  however,  limited  to  tliis  part,  and  sometimes  a  mass  of  soft 
brain-like  substance  is  found  in  the  midst  of  the  tumor,  surrounded 
by  the  delicate  cysts  and  gelatinous  substance  of  alveolar  cancer  ; 
while  at  other  times  the  medullary  matter  seems  altogether  fluid, 
and  on  cutting  through  the  tumor  it  issues  forth  from  some  of  the 
irre<^ular  cavities  which  have  been  already  spoken  of. 

The  peculiarities  of  the  nuitter  contained  in  the  cells  of  colloid 
cancer  have  been  frequently  referred  to  ;  and  even  in  growths  of 
consideral)le  magnitude  these  characters  are  sometimes  still  pres- 
ent in  a  marked  degree.  Often,  however,  they  are  more  or  less 
modified  by  the  same  causes  as  influence  the  contents  of  other 
forms  of  ovarian  cysts,  and  the  viscid  secretion  is  often  dark  from 
the  admixture  of  blood;  sometimes  even  of  a  dark  chocolate  color, 
sometimes  grumous;  but  I  do  not  think  that  it  becomes  purulent, 
as  is  not  infrequently  the  case  with  the  secretion  of  the  other 
ovarian  cysts. 

One  form  of  ovarian  cyst  still  remains  for  notice,  and  it  is  one 
concerning  which  some  problems  still  remain  unsolved.  Cysts  are 
sometimes  formed  in  the  ovary,  either  alone,  or  associated  with 
cystosareoma  of  the  organ,  containing  fat,  hair,  teeth,  or  other  pro- 

1  Remains  of  the  septa  may  in  these  cases  be  discovered  by  means  of  the  mi- 
croscope, in  the  midst  of  the  colloid  material.  It  was  the  observation  of  this  fact 
which  led  V^irchow,  Verhandlunpen  der  Gesellschaflf.  Gehurts/tii/fe,  vol.  iii,  p.  197, 
to  the  assumption  that  all  compound  ovarian  cysts  ai'o  in  realit}'  instances  of  colloid 
disease  of  the  organ  in  which  this  liquefaction  and  disappearance  of  the  septa  has 
taken  place.  This  theory,  however,  in  the  extension  given  to  it  by  Virchow,  is 
now  generally  regarded  as  untenable.  Indeed,  it  is  b\'  no  means  unusual  to  meet 
withcompound  ovarian  cysts  which  present  no  similarity  either  in  their  structure 
or  in  the  nature  of  their  contents  to  alveolar  cancer;  and  I  believe  that  the  micro- 
scope fully liears  out  the  verdict  which  observation  without  its  aid  would  induce 
us  to  return. 


FAT-CYSTS    OF    THE    OVARY.  403 

ducts  of  cutaneous  tissue.  The  presence  of  scales  of  cliolesterine, 
or  of  small  quantities  of  fat,  is  indeed  often  observed  both  in  sim- 
ple and  in  compound  ovarian  cysts,  and  is  due  to  the  rapid  for- 
mation and  rapid  desquamation  of  their  epithelial  lining,  and  to  the 
alterations  which  the  corpuscles  undergo.  In  tliese  cysts,  however, 
fat  is  present  in  much  larger  quantities,  so  that  it  forms  a  layer  on 
the  surface  of  the  fluid  removed  by  tapping  as  firm  as  lard,  or  even 
firmer;  or  collects  perhaps  into  large  irregular  flakes  or  masses, 
or  else  into  a  number  of  small  l)alls  like  marbles,  of  a  yellow 
color,  and  of  the  consistence  of  tallow,  shaped  into  these  symmet- 
rical forms  by  mutual  attrition  in  the  fluid  which  partly  filled  the 
cysts,  of  which  there  is  a  remarkable  specimen  in  the  museum  of 
Guy's  Hospital.'  Sometimes  the  cyst  contains  no  fluid,  but  a 
matter  of  the  appearance  and  consistence  of  putty,  possibly  inter- 
mingled with  hair.  Hair,  indeed,  is  often  met  with  in  these  cysts, 
sometimes  in  shapeless,  tangled  masses,  but  more  frequently  rolled 
together  into  round  balls;  and  teeth,  bone,  and  bone  cartilage  are 
also  all  found  in  many  instances.  When  it  liad  been  clearly  ascer- 
tained that  these  structures  existed  independently  of  impregnation, 
it  was  next  assumed  either  that  they  were  the  relics  of  some  im- 
perfectly developed  germ  included  by  accident  within  that  ovule 
which  had  gone  on  to  perfection,  and  that  they  were  therefore 
congenital  formations,  or  else  that  the  ovule  itself  was  capable  of 
a  certain  imperfect  attempt  at  growth,  independent  of  its  appro- 
priate vivifying  power,  and  thus  produced  incompletely,  and  with 
no  orderly  arrangement,  some  of  the  materials  of  the  foetus. 

In  a  measure,  too,  both  of  these  theories  are  probably  correct, 
though  cutaneous  cysts  are  found  in  circumstances  which  do  not 
seem  to  admit  of  either  of  tliese  solutions.  In  all  such  cysts  there 
may  be  found  any  of  the  products  of  dermoid  tissue  regularly 
formed,  as  though  growing  in  their  natural  situations ;  the  hairs 
im[)lanted  in  a  perfectly  normal  manner  into  the  cutaneous  tissue, 
wdiich  is  found  to  be  supplied  with  perspiratory  and  sebaceous 
follicles,  while  the  teeth,  in  different  stages  of  development,  are 
imbedded  in  tooth-sacs.  We  owe  the  observations  which  have 
removed  cases  of  this  kind  from  the  domain  of  the  wonderful,  and 
have  shown  how  method  and  order  reign,  where  a  more  imperfect 
knowledge  could  discover  nothing  but  mere  freaks  of  nature,  to  the 
acuteness  of  a  German  physician.*  Another  of  his  countrymen 
has  done  much  to  complete  our  information,  and  I  will  briefly 
state  to  you  the  results  at  which  he  has  arrived.  Dr.  Steinlin,'  on 
examination  of  the  body  of  a  young  woman  Irom  whom  seventy- 
eight  pounds  of  pus  were  removed  in  four  successive  tapftings, 
found  that  while  the  left  ovary  contained  several  small  cysts,  none 
of  which  exceeded  the  size  of  a  hazel-nut,  the  right  ovary  was  the 
principal  seat  of  disease.     It  was  made  up  of  many  cysts,  all  of 

'  No.  2237-*.  Rokitan>ky  also  relates  a  remarkable  case  of  a  sonio\vl)at  similar 
kind,  op.  cit.,  vol.  iii,  ]i.  ;')'.i7. 

2  Dr.  Kolilrau.«cli,  in  Muller's  Archiv,  1843,  p.  305. 
'  Zeitschrift  f.  Rationelle  Medizin^\o\.  ix,  p.  14G. 


404  STRUCTURE    OF 

wMch,  with  the  exception  of  one  large  sac  containing  several 
pounds  of  pus,  were  f'at-cjsts,  varying  from  the  size  of  a  grain 
of  linseed  to  three  or  four  inches  in  diameter.  The  flit  was  in  dif- 
ferent conditions  in  diiferent  cysts,  and  in  the  other  cysts  was  often 
intermixed  with  hairs  intertwined  into  a  mass.  All  the  contents 
being  removed,  the  greater  part  of  the  cyst-wall  was  seen  to  be 
smooth  and  shining,  but  there  were  one  or  more  round  islands,  of 
a  dull  whitish  color,  with  a  wart-like  prominence  in  their  centre, 
overgrown  with  hair;  and  other  similar  spots  without  the  wart- 
like prominence,  and  without  the  growth  of  hair,  but  with  several 
teeth  or  portions  of  bone  more  or  less  buried  under  their  surface. 

The  cyst-wall  admitted  of  division  into  several  layers.  Of  these 
the  outermost  was  composed  of  loose  ceHular  tissue,  beneath  which 
was  a  denser  layer  made  up  of  fibres,  which,  though  interlaced,  had 
on  the  whole  a  parallel  arrangement;  under  this  was  a  layer  of 
elastic  tissue,  and  innermost  of  all  a  coating  of  epithelium.  The 
epithelium  was  everywhere  of  the  tessellated  kind,  and  at  the 
polished  parts  of  the  cell  were  round  and  regular,  but  at  the  dull 
parts  the  superficial  layer  was  arranged  irregularly,  though  round 
cells  were  regularly  disposed  beneath.  On  denuding  the  wart-like 
prominences  of  their  epithelium,  the  subjacent  surface  exactly  re- 
sembled that  of  the  true  skin,  having  well-developed  papilla,  and 
the  whole  of  the  cyst-wall  beneath  the  unpolished  islets  had  a 
similar  structure.  The  hairs  growing  here  sprouted  from  a  regular 
bulb,  and  there  were  sebaceous  glands  and  perspiratory  follicles 
in  varying  number.  The  quantity  of  hairs  is  accounted  for  by 
their  being  deciduous,  though  formed  in  the  natural  manner,  and 
the  fat  is  not  secreted  by  the  whole  interior  of  the  cyst,  but  by  the 
sebaceous  glands,  just  as  the  vernix  caseosa  is  in  the  ibetus.  Th'e 
presence  of  teeth  is  explained  by  their  being  true  products  of  der- 
moid tissue,  so  that  wherever  that  tissue  is  found  there  always  exists 
tiie  possibility  of  teeth  being  developed;  and  their  presence  in  the 
jaws  is  a  sort  of  accident  b}^  no  means  essential  to  tlieir  formation. 

Dr.  Steinlin  concludes  that  the  development  of  the  cyst  is  but  a 
secondary  occurrence;  that  the  first  step  in  these  cases  is  the 
formation  of  a  tissue  exactly  identical  with  the  external  skin,  the 
accumulation  of  its  secretions  by  degrees  distending  the  investing 
membrane.  The  earliest  appearance  of  one  of  these  tumors  is  as 
a  small,  fleshy-looking  mass,  of  the  size  of  a  grain  of  hnseed,  in 
the  situation  of  a  Graafian  follicle,  and  surrounded  by  a  small  sac. 
In  the  course  of  time  this  small  body  becomes  detached  from  the 
sac  except  at  one  point,  where  its  stem  remains,  and  where  vessels 
having  a  looped  arrangement  enter  it.  Next,  a  thin  layer  of  fat 
is  found  between  the  small  lump  and  the  sac,  and  on  careful 
examination  of  the  former  the  sebaceous  follicles  are  now  seen 
developed.  With  the  increase  of  their  numbers  the  fat  increases, 
and  the  sac  becomes  distended,  Avhile  the  perspiratory  follicles 
modify  by  their  secretion  the  contents  of  the  sac. 

If  to  this  description  one  adds  that  the  intimate  relation  between 
pus  and  fat  globules  may  be  taken  as  explaining  the  general 


8 

98 

28 

215 

14 

41 

19 

92 

FAT-CYSTS     OF    THE    OVARY.  405 

presence  of  pus  in  fat-cjsts  of  any  considerable  size,  I  tliink  that 
the  description  of  this,  as  of  the  other  forms  of  cystic  ovarian 
tumor,  may  be  regarded  as  complete,  in  so  far  at  least  as  the  prac- 
tical object  of  these  lectures  is  concerned. 

Two  points,  however,  still  remain  which  rerpiire  a  brief  notice: 
namely,  the  comparative  frequency  of  disease  of  one  or  other,  or 
of  both  ovaries,  and  the  comparative  frequency  of  the  ditiivrent 
varieties  of  ovarian  disease. 

AVith  reference  to  the  first  of  these  questions,  the  general  evi- 
dence of  statistics,  as  the  subjoined  table  shows,  goes  to  prove  the 
preponderating  frequency  of  affection  of  the  right  ovary. 

Right  Ovary.  Left  Ovary.    Both  Ovaries.    Total. 

Cases  collected  hj  S.  Lee,i  50  35 

"  "  Chdreau,2  109  78 

"     observed  by  Scanzoni, 3  14  13 

"  "         "  the  author,  35  38 

208  164  69  441 

This  table,  however,  can  be  regarded  only  as  a  very  rougli  ap- 
proximation to  the  truth  in  this  matter,  since  it  is  mainly  deduced 
from  observations  made  during  the  life  of  the  patient,  while  it  is 
often  a  matter  of  considerable  difficulty  to  determine  whetljcr  a 
tumor  is  formed  by  the  right  or  by  the  left  ovary  ;  and  harder  still 
to  decide  that  the  disease  is  limited  to  one  ovary,  and  that  the 
organ  on  the  opposite  side  is  healthy.  In  two  instances,  indeed, 
in  addition  to  those  enumerated  in  the  table,  I  found  myself  quite 
unable  to  determine  which  ovary  occasioned  the  tumor,  and  very 
likely  in  some  other  cases  the  conclusion  which  I  did  come  to  was 
erroneous.  This  difiiculty,  too,  arises  not  simply  from  the  mesial 
position  of  the  tumor  at  the  time  when  the  case  comes  under 
observation,  and  from  the  inattention  of  the  patient  to  her  own 
early  sym|)toms,  though  that  is  very  frequent,  but  also  from  the 
circumstance  that  the  ligamentum  ovarii  becomes  twisted  occa- 
sionally as  the  organ  increases  in  size,  so  tliat  a  tumor  of  the  left 
ovary  sometimes  produces  enlargement  of  the  right  rather  than  of 
the  left  half  of  the  abdomen. 

Observation  after  death,  too,  fails  to  bear  out  the  alleged  greater 
frequency  of  the  disease  on  one  side  than  on  the  other,  while  it 
shows  that  the  affection  tends  far  oftener  than  would  ap}>ear  from 
the  former  table  to  involve  l)oth  ovaries.  Scanzoni's  figures  were 
deduced  from  post-mortem  examinations,  and  if  to  them  be  added 
24  of  my  own,  and  15  of  Dr.  II.  Lee's  ca8es,^a  total  is  obtained  ot 
80  cases,  in  28  of  which  the  disease  occupied  the  right  side,  in  26 
the  left,  and  in  26  both  ovaries.  This  result,  too,  tallies  with  that 
which  we  might  reasonably  anticipate  beforehand,  for  to  the  best 
of  my  knowledge  there  is  no  ground  for  the  sjiecial  liability  of 
one  ovary,  or  for  the  special  immunity  from  disease  of  the  other. 

1  On  Tii7nors  of  the  Uterus,  etc.,  8vo.,  London,  1847,  p.  120. 

2  As  quoted  by  Scanzoni,  op.  cit.,  p.  418.  *  Ibid. 
*  On  Ovaihni  and  Uter'me  Diseases.     London,  1853. 


406  OCCASIONAL    ARREST 

Professor  Scanzoni  is,  I  believe,  the  only  writer  who  has  at- 
tempted any  numerical  estimate  of  the  comparative  frequency  of 
the  different  varieties  of  cj'stic  disease  of  the  ovaries.*  His  41 
cases  and  my  24  yield  the  following  results  : 

Simple  cysts, in  16  cases. 

Fat-cysts, "     2     " 

Compound  cysts,  and  cystosarcomata, .     ...  "  23     " 

Colloid,  or  alveolar  tumors, "  21     " 

Cancer  with  cyst-formation, "     3     " 

Total, 65 

It  must  be  reserved  for  the  next  Lecture  to  consider  what  becomes 
of  these  tumors;  to  examine  how  nature  endeavors,  too  often 
fruitlessly,  to  effect  their  cure,  and  how  the  disease  tends  too  gen- 
erally and  too  inevitably  to  increase,  and  as  it  increases  to  bring 
added  suffering,  and  to  hasten  the  approach  of  death. 


LECTURE    XXVI. 

OVARIAN  TUMORS  AND  DROPSY. 

General  cockse  of  the  affection;  exceptional  character  of  the  cysts  of  the 
Wolffian  bodies — their  disposition  to  remain  stationary.  Occasional  arrest  of 
growth  of  simple  cysts  usually  temporary — their  complete  removal  very  rare. 

Cj-st  sometimes  discharges  its  contents  through  Fallopian  tube,  vagina,  intestine, 
externally,  or  into  peritoneum. 

Changes  in  cysts,  their  gradual  softening.  Inflammation  of  cysts.  Disorder  of 
health  from  pressure  of  cyst  on  viscera;  cachexia  attending  the  increase  of 
cyst.     Various  modes  of  death. 

Causes  predisposing  to  ovarian  dropsy — influence  of  age,  marriage,  and  child- 
bearing. 

Alleged  exciting  causes  of  the  disease. 

The  study  of  the  anatomy  of  ovarian  cysts  and  tumors  which 
occupied  us  at  the  last  Lecture,  has  enabled  us  now  to  advance  a 
step  further  in  our  investigations,  and  to  inquire  what  is  tlieir 
course^  and  what  their  tendency^  what  efforts  nature  makes  to  effect 
their  cure,  and  what  are  the  different  ways  in  which  they  frove  fatal? 

It  has  been  already  stated  that  practitioners,  though  ignorant  of 
their  real  nature,  were  long  familiar  with  the  occasional  presence 
of  thin-walled  cysts  between  the  folds  of  the  broad  ligament, 
which,  unlike  other  cysts  connected  with  the  substance  of  the 
ovary,  had  no  disposition  to  increase  beyond  comparatively  small 
dimensions.  I^ot  unnaturally,  however,  they  indulged  the  favor- 
able anticipations  which  were  justified  only  in  the  case  of  a  pe- 
culiar and  infrequent  affection,  with  reference  also  to  a  great 
number  of  simple  ovarian  cysts.  Utterly  unfounded  expectations 
of  the  disease  eventually  becoming  stationary  have  thus  on  several 

»  Op.cit.,  p.  418. 


OF    SIMPLE    OVARIAN    CYSTS.  407 

occasions  within  my  own  knowledge  deterred  patients  from  justly 
estimating  their  own  condition  and  prospects,  and  from  consent- 
ing, while  there  was  yet  time,  to  the  adoption  of  any  curative 
measures.  It  is  therefore  of  importance  to  bear  in  mind  that  the 
only  cysts  concerning  which  the  disposition  to  remain  stationary 
can  he  predicated  as  their  general  characteristic  are  the  cysts  of 
the  Wolffian  bodies;  and,  further,  that  these  cysts  have  scarcely 
ever  been  met  with  exceeding  the  size  of  an  orange,  while  even 
such  dimensions  are  unusual,  and  in  by  far  the  greater  number  of 
instances  they  reveal  themselves  by  no  symptoms  during  life,  and 
present  themselves  to  the  anatomist  far  oftener  than  to  the  physi- 
cian. One  case,  indeed,  and  but  one,  has  come  under  my  own 
notice,  concerning  which  I  could  feel  justified  in  assuming  that 
the  cyst  was  not  ovarian,  but  was  connected  with  the  remains  of 
the  Wolfiian  body.  The  i)atient,  who,  when  she  first  came  under 
my  notice,  was  fifty  years  old,  remained  for  eight  3'ears  under  my 
observation  ;  and  the  tumor  which  was  connected  with  the  right 
uterine  appendages  continued  during  the  whole  time  of  the  same 
dimensions,  being  rather  smaller  than  the  foetal  head  until,  with- 
out any  symptom,  it  suddenly  disap})eared,  its  thin  walls  having 
doubtless  given  way,  and  its  contents  having  escaped  into  the 
peritoneal  cavity.  The  tumor  was  extremely  movable,  floating 
loosely  just  above  the  pelvic  brim,  but  occasionally  sinking  down 
into  its  cavity,  and  then  producing  discomfort  of  various  kinds, 
by  its  pressure  on  the  parts  situated  there,  and  es[)ecially  by  the 
obstruction  it  offered  to  emptying  the  l)ladder,  symptoms  which, 
with  its  disappearance,  completely  ceased.  This,  however,  is  in 
my  experience  a  solitary  instance  of  a  cyst  connected  with  the 
uterus  remaining  quite  stationary  at  a  small  size  ibr  years  ;  so 
that  I  fear  we  must  regard  the  chances  as  being  against  the  more 
hopeful  view  of  the  nature  of  any  of  these  tumors,  and  must 
furtlier  look  upon  the  mere  fact  of  the  cyst  having  attained  a 
greater  size  than  that  of  a  large  orange,  or  of  the  foetal  head,  as 
decidedly  negativing  it.  The  arrest  of  tlie  disease  may  indeed 
still  be  hoped  for  as  a  lucky  accident;  it  can  no  longer  be  counted 
on  as  a  probable  occurrence. 

I  said  that  the  arrest  of  the  disease  may  in  any  case  of  simple 
ovarian  cyst  be  looked  for  as  a  lucky  accident;  and,  indeed,  I  do 
not  know  how  more  fitly  to  designate  it,  for  the  nice  adjustment 
of  the  balance  between  exhalation  and  absor})tion  depends  on  con- 
ditions which  remedies  cannot  bring  about,  which  diagnostic  skill 
cannot  even  foretell.  It  is  not  in  general  while  in  the  pelvic  cavity 
that  this  arrest  occurs  ;  for  though  the  growth  of  the  tumor  may 
then  be  slow,  it  is  while  situated  there  liable  to  be  pressed  on, 
irritated,  excited  by  the  vaiying  condition  of  the  adjacent  viscera. 
After  it  has  risen  al)ove  the  pelvic  brim,  this  fortunate  occurrence 
sometimes  takes  place,  though  it  takes  place  but  very  rai-ely,  for, 
though  the  cyst  is  no  longer  irritated  as  it  was  before,  its  increase 
is  not  now  restrained  by  unyielding  boundaries,  and  hence  it  fre- 
quently enlarges  with  greater  ra[iidity.     As  a  general  rule,  the 


408  OCCASIONAL    SPONTANEOUS 

enlargement  goes  on,  not  continuously,  indeed,  but  by  fits  and 
starts,  till  at  length  the  size  of  the  abdomen  causes  distress,  and 
necessitates  interference.  The  exception  is  met  with  in  instances 
where  the  cyst  having  attained  a  size  somewhat  less  than  that  of 
the  adult  head,  begins,  to  the  patient's  surprise  and  pleasure,  to 
diminish,  becomes  notably  smaller  than  it  once  had  been,  though 
it  scarcely  ever'entirely  disappears,  but  remains  for  years,  possibly 
even  for  the  remainder  of  the  patient's  life,  a  source  of  apprehen- 
sion and  an  occasion  of  some  discomfort,  but  not  of  much  actual 
suftering,  or  of  serious  injury  to  the  health. 

In  March,  1853, 1  saw  a  single  woman,  aged  thirty-one,  in  whom 
the  development  of  an  ovarian  cyst  had  succeeded  to  a  heavy  fall 
on  the  nates  three  years  before.  Her  abdomen  on  admission 
measured  thirty-seven  and  a  half  inches  at  the  umbilicus;  and  its 
increase  was  alleged  to  have  been  going  on  with  rapidity;  and  the 
patient  was  anxious  even  to  undergo  some  risks  for  the  chance  of 
being  \3ured  of  an  ailment  now  threatening  to  become  the  source 
of  much  suffering.  She  was  ordered  to  keep  her  bed  for  a  few 
days,  in  order  that  a  careful  examination  of  her  abdomen  and  of 
the  relations  of  the  tumor  might  be  made.  In  a  week  the  abdo- 
men measured  only  tbirty-five  inches;  and  in  another  fortnight 
only  thirty-four.  I  need  hardly  say  that  in  these  circumstances 
the  patient  was  advised  neither  to  be  tapped  nor  to  have  any  other 
operation  attempted.  She  returned  to  the  country,  and  to  her 
occupation  as  a  village  schoolmistress.  In  April,  1855,  ber  abdo- 
men measured  little  more  than  thirty-five  inches;  and  tapping  did 
not  become  necessary  until  between  four  and  five  years  afterwards. 

To  a  slighter  degree,  and  for  a  shorter  time,  the  partial  absorp- 
tion of  the  contents  of  an  ovarian  C3'st  is  by  no  means  uncommon; 
and  no  one  can  have  seen  much  of  ovarian  dropsy  without  having 
been  struck  by  the  different  degrees  of  tension  which  the  tumor 
at  dilferent  times  presents.  Sometimes  it  is  so  tense  and  firm  as 
to  seem  almost  solid,  and,  indeed,  if  the  growth  be  but  small,  this 
extreme  tension  of  its  walls  may  so  obscure  the  sense  of  fluctua- 
tion as  to  lead  the  observer,  unless  very  carefully  on  the  watch, 
into  error.  At  other  times  not  only  is  fluctuation  most  distinct, 
but  the  cyst-wall  is  so  flaccid  that  if  the  tumor  is  large  it  may 
not  be  very  easy  to  distinguish  between  an  encysted  dropsy  and 
'ascites.' 

It  is  not  easy  to  determine  the  cause  of  such  fluctuations  in  the 
condition  of  the  cyst.     A  connection  may  now  and  then  be  ob- 

1  Cruvcilhior,  Anrttomie  Pathol.,  vol.  iii,  p.  400,  speaks  of  a  variety  of  ovarian 
cysts  as  kysfes  vniload aires  flnsquen,  and  describes  them  as  retaining  a  remarkable 
fiaccidity  of  their  walls  in  spite  even  of  having  attained  a  very  considerable  size. 
He  further  gives  the  details  of  a  case  in  which  these  characters  led  two  very  dis- 
tinguished physicians  into  the  error  of  mistaking  an  ovarian  drojtsy  for  ascites. 
These  flaccid  cysts  seem  to  cause  comparatively  small  discomfort,  to  interfere  but 
little  with  the  general  health,  and  to  give  rise  to  no  symptoms  such  as  to  justify 
tapping.  One  such  case  I  saw  quite  recently,  in  which  it  was  not  till  after  I  had 
carefully  examined  the  abdomen  several  times  that  I  came  to  the  decision  that  the 
fluid  was  encysted. 


CURE    OF    OVARIAN     DROPSY.  409 

served  between  the  approach  of  a  menstrual  period  and  an  en- 
largement and  increased  tension  of  the  cyst,  while  it  once  more 
grows  smaller,  and  its  walls  become  flaccid  as  menstruation  passes 
otf.  In  the  majority  of  cases,  however,  no  approach  to  regular 
periodicity  in  these  changes  can  be  observed,  though  even  when 
the  disease  goes  on  tolerably  uninterruptedly  from  bad  to  worse, 
there  are  yet  almost  always  seasons  during  which  it  remains 
stationary,  followed  by  times  of  rapid  increase.  The  increase  of 
the  tumor,  too,  sometimes  takes  place  noticeably  in  the  course  of 
twelve  or  twenty-four  hours;  the  suddenness  of  the  enlargement 
showing  it  to  be  due  to  a  rapid  effusion  into  the  cavity  of  the  cyst, 
not  to  the  comparatively  slow  process  of  growth. 

If  the  contents  of  an  ovarian  cyst  may  then  vary  from  time  to 
time,  there  certainly  can  be  no  reason  why,  in  some  instances,  the 
process  of  absorption  may  not  go  on  so  as  to  effect  the  entire  re- 
moval of  the  fluid  and  the  complete  cure  of  the  patient.  Such  an 
occurrence,  however,  appears  to  be  of  extreme  rarity,  and  some 
most  competent  authorities  have  even  discredited  it  altogether.' 
In  one  case  I  believe  that  I  witnessed  it  in  the  person  of  a  young 
married  woman,  who  had  vague  symptoms  of  discomfort  about  her 
uterus  for  nine  months,  and  had  been  aware  of  the  existence  of  a 
tumor  for  four  months  before  her  admission  into  the  hospital. 
The  tumor,  which  was  connected  with  the  left  ovary,  was  tapped 
per  vaginam,  and  sixteen  ounces  of  highly  albuminous  fluid  were 
withdrawn.  It  was  determined  tliat  so  soon  as  the  cyst  had  re- 
gained its  former  dimensions,  tapping  should  be  repeated,  and  a 
solution  of  iodine  be  injected,  in  order  to  prevent  the  reaccuniu- 
lation  of  the  fluid.  On  the  forty-second  day  after  the  first  tapping 
this  operation  Avas  to  have  been  done  ;  but  it  then  struck  some 
who  were  present  that  the  tumor  had  seemed  larger  a  day  or  two 
previously  than  it  was  then.  The  operation  was  postponed;  and 
day  by  day  the  tumor  shrank,  not  suddenly  as  if  from  rujjture  oi 
its  walls,  nor  with  any  discharge  per  vaginam  suggestive  of  a  com- 
munication existing  between  it  and  the  Fallopian  tube,  but  by 
degrees,  as  if  its  contents  were  gradually  absorbed.  Fourteen 
days  afterwards,  or  on  the  fifty-sixth  day  from  the  first  tapping, 
all  traces  of  the  tumor  had  disappeared.  Another  case  lias  come 
to  my  knowledge  of  the  disappearance  of  an  ovarian  tumor  in  a 
lady  from  whom  seven  pints  of  deep  amber-colored  glutinous  fiuid 
were  removed  by  tapping  five  weeks  before  the  birth  of  her  fourth 
child.  Her  labor  was  quite  natural,  but  nineteen  da^-s  afterwards, 
while  seated  on  the  sofa,  she  was  attacked  by  sudden  violent  pain, 
with  great  fiiintness,  and  s^'mptoms  of  rupture  of  the  cyst,  f)l lowed 
by  those  of  general  peritonitis,  for  which  she  was  treated  very 
actively.  Iler  abdomen  at  this  time  became  swollen  to  double 
the  size  which  it  had  presented  when  she  was  tap[>ed.  In  tlie 
course  of  two  months,  however,  this  general  enlargement  sub- 

'  Kiwisch  and  Scanzoni,  two  of  the  most  recent  and  of  the  highest  authorities, 
most  completely  discredit  its  occurrence. 


410  OVARIAN    CYSTS    MAY    EMPTY    THEMSELVES 

sided,  disclosing  a  distinct  elastic  tumor  occupying  the  hypo- 
gastric and  right  iliac  regions.  This  next  shrank  gradually,  so 
that  at  the  end  of  nine  months  from  the  patient's  confinement  I 
could  scarcely  find  any  trace  of  it;  and  after  a  natural  pregnancy 
she  was  confined  of  her  fifth  child,  two  years  and  a  month  after 
her  former  labor.  On  this  occasion  the  medical  man  who  attended 
her,  and  who  had  watched  her  through  all  her  previous  illness, 
searched  in  vain  for  any  traces  of  the  tumor.  In  this  second  case 
there  can  be  little  doubt  but  tliat  some  connection  existed  between 
the  attack  of  peritoneal  inflammation  in  which  the  cyst  itself  was 
involved  and  the  subsequent  complete  disappearance  of  the  tumor. 
In  the  former  instance,  however,  no  symptom  whatever  attended 
the  removal  of  the  fluid  ;  but  though  we  do  not  understand  the 
means  by  which  it  was  efteeted,  still  the  removal  of  the  fluid  is 
scarcely  more  inexplicable  than  the  permanent  cure  which  occa- 
sionally follows  a  single  tapping,  in  cases  where  yet  neither  con- 
stitutional disturbance  nor  local  suffering  has  Ibllowed  the  opera- 
tion.' 

The  simple  absorption  of  their  contents  is,  indeed,  the  rarest  of 
all  the  changes  which  take  place  in  ovarian  cysts.  A  much  more 
common  occurrence,  and  one  by  which  their  increase  is  for  a  time 
arrested,  and  their  complete  cure  now  and  then  effected,  is  their 
rupture,  and  the  escape  of  their  contents  through  various  channels, 
the  empty  cyst  ceasing,  perhaps  for  a  time,  perhaps  forever,  to  per- 
form its  secretory  function. 

An  ovarian  cyat  may  empty  itself  through  the  Fallopian  tube,  the 
most  fortunate,  but  by  no  means  the  most  frequent,  outlet  for  its 
contents  ;  through  the  vagina,  through  the  intestine,  or  even 
through  the  bladder;  or  it  may  burst  into  the  cavity  of  the  peri- 
toneum, or,  forming  adhesions  with  the  abdominal  walls,  may 
pour  out  its  contents  at  or  near  the  umbilicus. 

Each  of  these  outlets  needs  a  moment's  notice;  and,  first,  of 
that  which  is  formed  by  the  dilated  Fallopian  tube.  Cases  are 
sometimes  met  with  in  which,  on  examination  of  the  body  after 
death,  the  fimbriated  extremit}'  of  the  Fallopian  tube  is  found 
adherent  to  an  ovarian  cyst,  and  expanded  over  it,  while  the  tube 
itself  is  distended  at  its  abdominal  extremity,  and  presents  all  the 
characters  of  dropsy.  On  pressure  upon  the  cyst,  however,  it  is 
found  that  the  fluid  can  pass  readily  from  it  into  the  tube,  while 
in  most  instances,  and  quite  contrary  to  what  might  be  expected, 
no  mechanical  obstacle  is  found  closing  the  uterine  end  of  the 
canal.  The  communication  between  the  cyst  and  the  tube  is, 
however,  free  enough  to  admit  the  point  of  the  index  finger,  a 
sliirht  contraction  marking  its  situation,  and  the  longitudinal  ar- 

^  ...  Ill 

rangement  of  the  fibres  indicating  the  commencement  of  the  tube. 
The  mere  tonicity  of  the  parts  prevents  the  ready  escape  of  the 
fluid  at  the  uterine  end  of  the  tube.     It  collects  in  the  canal,  dis- 

1  A  case  of  gradual  disappearance  of  a  well-marked  ovarian  cyst  is  related  by 
Dr.  Huss  in  Monatschriftf.  Gehui'tskunde,  Feb.  1857,  vol.  ix,  p.  143. 


THROUGH    VARIOUS    CHANNELS,  411 

tending  by  degrees  its  abdominal  extremity,  and  at  length  escap- 
ing throngb  the  womb  only  when  it  has  dilated  the  whole  length 
oftlie  tube,  and  overcome  the  natural  resistance  of  its  walls.  A 
gush  of  fluid  then  takes  place  by  the  vagina,  and  the  cyst  is  partly 
or  even  completely  emptied,  though  such  discharges  do  not  in 
general  effect  a  permanent  cure,  but  the  cyst  retills,  the  tube 
becomes  redistended,  and  the  same  process  may  be  several  times 
repeated.  Such  at  least  appears  to  be  the  opinion  of  M.  Adolphe 
Richard,*  who  has  described  these  cases  very  minutely,  and  who 
suggests,  and  with  much  plausibility,  that  many  of  the  instances 
of  alleged  communication  of  ovarian  cysts  with  the  vagina  were 
in  reality  instances  of  tlioir  opening  into  the  Fallopian  tube. 

No  opportunity  of  studying  this  process  has  presented  itself  to 
me  after  death ;  and,  indeed,  I  am  disposed  to  believe  that  it  is  a 
rare  occurrence,  since  I  have  met  with  but  one  instance,  out^f  the 
ninety-four  cases  on  which  my  remarks  are  founded,  where  the 
cyst  appeared  to  empty  itself  in  this  manner.  The  patient  in  that 
case  was  a  married  woman,  thirty-six  years  of  age,  whose  aljdomen 
first  began  to  enlarge  six  years  before  her  admission  into  the  hos- 
pital. After  having  acquired  a  considerable  size,  the  swelling 
suddenly  disappeared  during  a  profuse  watery  discharge  from  the 
vagina;  and  the  same  occurrence  took  place  afterwards  eight  or- 
ten  times.  The  fluid  thus  discharged  was  colorless;  it  escaped 
with  a  gush,  amounted  sometimes  to  several  quarts,  and  the  sud- 
denness of  its  flow  not  infrequently  produced  faintness  or  actual 
syncope.  Sometimes  it  escaped  during  the  efibrt  at  defecation, 
but  most  commonly  its  flow  was  independent  of  any  such  exciting 
cause.  I  myself  ascertained  the  presence  of  a  distinctly  fluctuating 
tumor,  its  sudden  disappearance  fourteen  days  afterwards,  and 
then  the  slow  return  of  abdominal  enlargement  during  the  ensuing 
three  weeks,  when  I  lost  sight  of  the  patient. 

The  symptoms,  however,  were  so  characteristic,  that  I  imagine 
one  is  perfectly  justified  in  assuming  the  case  to  have  been  one  of 
communication  of  the  cyst  with  the  Fallopian  tube.  The  uterus 
itself  was  perfectly  movable,  rather  high  up  in  the  pelvis,  no 
aperture  existed  in  the  vagina,  nor,  indeed,  was  the  tumor  to  be 
distinctly  ielt  through  it;  but  it  evidently  floated  in  the  abdominal 
cavity  loosely  tethered,  as  an  unadherent  ovarian  tumor  often  is, 
by  the  elongated  uterine  appendages.  IIow  the  communication 
is  brought  about  between  the  ova'ry  and  the  tube  in  these  cases 
is  uncertain;  but  it  has  been  suggested,  with  considerable  plausi- 
bility, that  the  process  is  one  of  a  physiological  rather  than  ot  a 
pathological  character.     In  the  other  instances,  however,  inflam- 

»  Memoires  de  la  Soci'etf  de  Chirurgie,  vol.  iii,  18")3,  p.  121.  The  absence  of  any 
evidence  of  past  inflanimatorv  action  about  tlie  communication  between  the  ovary 
and  tlic  tube,  leads  M.  Kicliard  to  suppose  that  the  or'v^m  of  the  condition  dates 
back  to  a  byc;one  menstrual  period  ;  that  the  Graafian  vesicle  haviiii:  diseharijed 
its  ovule,  did  not  collapse  and  wither  as  it  usually  does,  but  still  retaining  its  com- 
munication with  the  tube,  enlarged,  became  dropsical,  and  thus  formed  what  ho 
lirujioses  to  term  a  tubo-ovarian  cyst. 


412         RUPTURE    OF    CYST    INTO    INTESTINAL    CANAL. 

mation,  the  formation  of  adhesions,  and  the  absorption  of  the  wall 
both  of  the  cyst  and  of  the  adjacent  viscus,  are  all  implied  in  the 
escape  of  the  fluid. 

Many  instances  are  on  record^  of  a  cyst  emptying  itself  per 
voginam  ;  and  this,  too,  even  if  we  exclude  those  concerning  which 
it  is  doubtful  whether  they  do  not  more  properly  belong  to  the 
class  described  by  M.  Richard.  Far  more  frequent,  however,  is  the 
formation  of  a  communication  between  the  cyat  and  the  intestinal 
canal.  Generally,  though  not  invariably,  this  communication  takes 
place  quite  low  down,  and  seems  to  be  due  to  the  pressure  of  that 
portion  of  the  cyst  which  occupies  the  pelvic  cavity  upon  the 
rectum,  and  the  consequent  absorption  of  the  walls,  both  of  the 
intestine  and  of  the  tumor.  Not  long  since  a  communication 
took  place  in  this  manner,  in  the  case  of  a  patient  of  my  own, 
between  a  large  sac  which  formed  part  of  a  compound  ovarian  cyst 
and  the  rectum  a  little  above  the  internal  sphincter.  Through  the 
opening,  which  was  of  the  size  of  a  crown-piece,  many  quarts  of  a 
darkgrumous  fluid  escaped  during  the  last  few  days  of  the  ])atient's 
life,  with  much  alleviation  of  her  suflerings,  and  with  conqdete 
removal  of  the  obstinate  constijiation  that  for  a  long  time  pre- 
viously had  been  maintained  by  the  mechanical  pressure  of  the 
tumor  on  the  intestine.  The  observation  of  this  and  of  similar 
cases  suggests  the  expediency  of  attempting  to  tap  the  tumor  per 
vaginam  whenever  serious  inconvenience  is  produced  by  its  pres- 
sure upon  the  intestine,  and  paracentesis  through  the  abdominal 
walls  has  cither  proved  unsuccessful,  or  has  aflbrded  but  yiartial  re- 
lief. In  the  instance  just  referred  to  very  little  fluid  was  obtained 
by  puncture  of  the  abdomen,  while,  had  a  trocar  been  introduced 
into  that  part  of  the  growth  that  projected  into  the  pelvis,  the 
principal  cyst  would  have  been  enq»tied,  and  the  patient's  suffer- 
ings, which  nature  mitigated  but  too  tardily,  would  long  before 
have  been  assuaged. 

Sometimes,  however,  communications  form  between  an  ovarian 
cyst  and  the  intestinal  canal  in  other  situations,  and  are  not  attrib- 
utable to  the  direct  eftl'Cts  of  pressure,  though  their  real  cause  is 
very  obscure.  Thus,  in  the  nmseum  of  Guy's  Hos[»ital  there  is  a 
preparation  of  an  ovarian  cyst,  at  whose  uj»per  part  an  opening 
has  formed  into  the  bowel.  A  patient  of  mine,  too,  in  whom  an 
ovarian  cyst  had  developed  itself  with  rapidity  in  the  course  of 
two  months,  and  who  experienced  much  abdominal  pain  and  ten- 
derness, suddenly  felt  a  sensation  as  if  something  had  given  way 
within  her,  and  was  imn\ediately  attacked  by  violent  diarrhoea.  In 
the  course  of  ten  hours  the  bowels  were  |)urged  twenty  times;  the 
evacuations  not  being  feculent,  but  consisting  of  a  dark  bloody 
fluid,  which,  under  the  microscope,  was  founcl  to  contain  many 
blood  globules,  and  also  many  pus  corpuscles,  as  well  as  some 
crystals  of  cholesterine.     The  tumor  had  now  completely  disap- 

*  Meissner's  Frauenlrankheiten,  vol.  ii,  p.  318,  contains  numerous  references 
illustrative  of  this  subject. 


KUPTURE     OF    CYST    INTO    PERITONEUM.  413 

peared,  and  five  weeks  afterwards  there  was  still  no  trace  of  it 
discoverable,  though  I  am  unable  to  say  whether  the  cure  was 
permanent. 

O^ienings  in  the  abdominal  parietes  are  another  channel  through 
which  ovarian  tumors  sometimes  empty  themselves.  In  one  in- 
stance which  1  saw  the  cyst  had  dilated  the  umbilical  ring,  and 
projected,  like  a  hernia  covered  by  the  thinned  integument,  some 
inches  beyond  the  surrounding  abdominal  walls.  In  this  thin  in- 
tegument an  opening  formed,  through  which  on  several  occasions 
the  cyst  partially  discharged  itself.  It  is,  however,  more  usual  for 
the  opening  to  take  })lace  below  the  navel,  adhesions  first  forming 
between  the  cyst  and  the  integuments.  The  opening  sometimes 
continues  long  fistulous,  though  I  have  known  it  to  close,  and 
discliarges  from  it  permanently  to  cease  without  any  special  change 
taking  place  in  the  condition  cither  of  the  tumor  or  of  its  contents. 
To  the  best  of  my  knowledge,  a  permanent  cure  less  often  ibllows 
the  discharge  of  the  contents  of  the  cj'st  through  the  abdominal 
walls  than  their  escape  through  some  other  channel. 

The  rupture  of  an  ovarian  cyst  into  the  peritoneal  cavity  is,  how- 
ever an  accident  of  far  more  frequent  occurrence  than  the  dis- 
charge of  its  contents  through  any  other  channel,  and  was  met 
with  in  6  out  of  94  cases  of  which  I  have  a  record.  In  one  of 
these  cases,  a  fjill  on  the  abdomen  produced  the  bursting  of  the 
cyst,  but  in  by  far  the  greater  number  of  instances  on  record  its 
rupture  has  been  independent  of  external  violence.  Sometimes 
the  delicate  cyst  gives  way  from  over  extension,  and  this  is  prob- 
ably the  explanation  of  its  sudden  disappearance  in  the  case  which 
I  referred  to  some  time  ago,  as  being  probably  an  instance  of  a 
tumor  connected  with  the  remains  of  the  Wolffian  body ;  as  also 
in  another  instance  where  a  tumor  half  the  size  of  the  adult  head 
suddenly  disappeared,  the  same  accident  having  occurred  to  the 
patient  eighteen  months  before.  In  other  cases  inflammation  and 
softening  of  the  cj'st-wall  have  preceded  its  rupture  ;  and  an  exam- 
ination after  deatli  discovers  it  red  and  congested,  and  the  edges 
of  the  rent  soft,  irregular,  and  jagged.  Sometimes  the  sac,  once 
ruptured,  does  not  refill,  and  a  permanent  cure  is  obtained,  though 
usuall}^  at  the  expense  of  an  attack  of  peritonitis ;  and  I  much 
fear  that  there  is  no  direct  or  constant  relation  between  the  severity 
of  the  inflammation  which  follows  the  rupture  of  the  cyst  and  the 
non-accumulation  of  the  fluid  afterwards.  One  of  my  cases  was 
that  of  a  young  lady,  aged  twenty-six,  in  whom  an  ovarian  cyst 
gave  way  twice,  and  whose  life  on  each  occasion  was  in  the  greatest 
jeopardy,  but  who  did  not  gain  thereby  the  slightest  delay  in  the 
ra})i(lity  with  which  the  fluid  re-collected.  In  two  other  cases  of 
mine  the  rupture  of  the  cyst  proved  fatal;  the  wall  having  in 
both  instances  given  way  at  the  posterior  part  of  the  tumor,  where 
it  was  closely  pressed  against  the  pelvic  brim,  and  extensive  eccliy- 
mosis  around  the  rent  attested  in  one  case  the  mechanical  obstacle 
which  had  existed  to  the  course  of  the  blood  in  that  situation.    In 


414  INFLAMMATION    OF 

the  other  case  decomposition  was  too  far  advanced  to  allow  of  any 
observation  as  to  the  state  of  the  cjst-wall. 

The  mortality  of  2  cases  out  of  6  agrees  very  nearly  with  that 
which  Dr.  Tilt*  deduces  from  a  collection  of  34  cases,  in  10  of 
which  death  followed  the  rupture  of  the  cyst.  In  20  of  the  cases, 
however,  the  fluid  did  not  re-collect,  but  I  feel  very  doubtful 
whether  a  more  numerous  collection  of  facts  would  be  found  to 
bear  out  the  conclusion  that  in  2  cases  out  of  3  the  escape  of  the 
cyst  contents  into  the  abdomen  is  followed  by  the  permanent  cure 
of  the  patient.'-' 

For  the  very  various  results  that  have  followed  the  escape  of 
the  fluid  of  ovarian  dropsy  into  the  abdomen  an  explanation  has 
been  suggested  by  Dr.  Simpson,'  and  adopted  by  Scanzoni.^  It 
is  supposed  that  the  difl'erent  characters  of  the  fluid  in  the  cyst 
determine  the  occurrence  or  non-occurrence  of  peritonitis;  that 
the  pure  serum  gives  rise  to  no  ill  eflbcts,  while  dangerous  peri- 
tonitis follows  the  escape  of  fluid  mixed  with  blood  or  with  the 
products  of  inflammation.  Still,  this  is  only  an  hypothesis,  ])roba- 
ble,  indeed,  but  not  proven,  and  wholly  insufficient  to  form  the 
basis  of  any  therapeutical  proceedings. 

Otlier  changes  take  place  in  ovarian  cysts^  tending  for  the  most 
part  less  to  the  cure  than  to  the  aggravation  of  the  evil.  Some  of 
these  changes  seem  incidental  to  the  process  of  growth,  as  for 
instance  the  removal  of  the  sc})ta  between  the  cysts,  the  gradual 
liquefaction  of  the  solid  matter,  and  the  consequent  conversion  of 
a  firm  into  a  distinctly  fluctuating  tumor.  This  alteration  is  in 
one  sense  of  bad  omen,  since  I  believe  its  occurrence  is  generally 
contemporary  with  the  more  rapid  increase  of  the  growth  ;  on  the 
other  hand,  however,  it  often  jdaces  within  our  reach  the  means 
of  mitigating  the  patient's  sutierings  by  tapping,  wliich  in  the 
earlier  stages  of  the  aflection  was  impracticable.  With  the  rapid 
growth  of  the  tumor  there  is  in  all  cases  of  compound  ovarian 
cysts  a  corresponding  increase  in  the  vessels  which  supply  it,  and 
a  consequently  greater  disposition  to  hemorrhage  into  its  cavity. 
Sometimes,  indeed,  the  admixture  of  blood  with  the  fluid  of  the 
cyst  is  so  considerable  as  no  doubt  to  have  had  a  large  sliare  in 
the  production  of  that  anaemia,  and  that  extreme  exhaustion  of 
strength  which  are  often  observed  in  patients  suffering  from  large 
ovarian  tumors. 

Of  all  the  morbid  processes,  however,  of  which  these  growths 
are  the  seat,  inflammation  is  the  most  common  and  the  most  im- 
portant. Few  cysts  attain  any  considerable  size  without  having 
been  attacked  by  it,  and  this  inflammation  is  of  all  the  greater 
moment,  since  it  is  seldom  limited  to  the  interior  of  the  cyst,  but 

J  Lancet,  Aug.  5,  1848,  vol.  ii,  p.  146. 

2  In  vol.  V,  p.  226,  of  Transactions  of  Pathological  Society,  a  case  is  related  by  Dr. 
Bristowc  of  rupture  of  an  ovarian  c^-st  into  the  abdomen,  the  aperture  remaining 
permanent,  the  cyst  still  continuing  to  secrete,  and  ascites  resulting  from  the  accu- 
mulation of  the  secretion  within  the  peritoneal  cavity. 

3  Op.  cit.,  vol.  i,  p.  247.  *  Op.  cit.,  p.  448. 


OVARIAN    CYSTS.  415 

generally  affects  its  outer  surface  likewise,  producing  adlicsions 
between  it  and  adjacent  organs,  and  thus  forming  great,  often 
insuperable  obstacles  to  the  success  of  various  operations  wliich 
have  been  proposed  for  the  cure  of  ovarian  dropsy.  In  a  practical 
point  of  view,  too,  this  inflammation  is  the  more  important  from 
being  often  unattended  by  local  suffering,  sometimes,  indeed, 
accompanied  by  a  comparatively  small  amount  of  constitutional 
disturbance,  so  that  it  is  almost  impossible  to  determine  anything 
with  certainty  concerning  its  occurrence  or  non-occurrence  from 
the  patient's  history.  Of  this  no  better  proof  can  be  given  than 
is  afforded  by  the  observation  of  cases  where  on  tap[)ing  a  cyst, 
instead  of  the  transparent  serum  which  it  was  supposed  to  con- 
tain, a  turbid  fluid  largely  mingled  with  pus  has  been  let  out,  or 
of  other  cases  in  which,  the  extirpation  of  the  tumor  having  been 
resolved  on,  universal  adhesions  have  been  found  connecting  it 
with  the  viscera,  and  with  the  abdominal  walls.  In  many  in-  ' 
stances  the  inflammation  issues  in  the  exudation  of  lymph  as  well 
as  in  the  outpouring  of  pus,  and  the  lining  membrane  ot  the  cyst 
is  found  roughened  and  thickened  by  its  deposit,  which  is  some- 
times so  abundant  that  it  may  be  stripped  ofl'just  as  may  the  false 
membrane  deposited  on  an  inflamed  pleura.  Multilocular  cysts 
are,  I  think,  more  liable  than  simple  cysts  to  this  occurrence  ;  and 
often,  even  where  the  diflerent  cavities  intercommunicate,  inflam- 
mation and  tlie  outpouring  of  lymph  may  be  found  in  one  cyst, 
and  no  trace  of  any  such  occurrence  be  observable  in  another 
immediately  adjacent. 

With  the  increase  of  the  tumor,  and  the  failure  of  the  patient's 
powers,  the  liability  to  inflammation  of  the  cyst  appears  to  in- 
crease also,  and  its  occurrence  contributes  to  hasten  the  fatal 
event.  It  is  but  seldom,  however,  except  after  tapping,  or  some 
other  operation,  that  cyst  inflammation  of  itself  proves  fatal ;  but 
many  causes  in  general  combine  by  slow  degrees  to  destroy  the 
patient. 

First  among  these  causes  may  be  mentioned  the  disorder  of  the 
functions  of  other  viscera,  as  the  tumor  by  its  increasing  size  presses 
upon  and  disturbs  them.  The  pregnant  uterus,  as  you  know,  even 
when  it  has  attained  its  largest  size,  interferes  but  little  with  the 
functions  of  other  organs.  The  intestines  find  room  on  either 
side  of  it,  while  the  direction  of  its  fundus  forwards  in  the  axis  of 
the  pelvic  brim  obviates  all  interference  with  the  descent  of  the 
diaphragm,  and  usually  prevents  all  disturbance  of  the  stomach  or 
liver.  The  ovarian  tumor,  on  the  other  hand,  as  it  increases  in 
size,  so  completely  fills  the  lateral  regions  as  to  leave  no  room  for 
the  intestines  except  behind  and  above  it,  where  they  are  often 
compressed  into  a  very  scanty  space.  No  such  law  governing  the 
direction  taken  by  the  tumor  as  regulates  the  enlargement  of  the 
pregnant  womb,  the  descent  of  the  (liai>hi:igm  becomes  earlier 
impeded,  and  respiration  is  thereby  rendei-ed  labored.  The  liver 
is  at  the  same  time  pressed  on  and  disturbed  in  the  performance 
of  its  functions,  and  this  just  at  a  time  when  the  active  discharge 


416  MODES    IN    WHICH 

of  its  duties  is  rendered  all  the  more  necessary  by  the  congestion 
of  the  abdominal  vessels  which  the  pressure  of  the  tumor  occa- 
sions, and  the  scanty  urinary  secretion  that  is  its  attendant  and 
its  consequence.^ 

In  a  large  proportion  of  cases  this  abdominal  congestion  relieves 
itself  by  the  effusion  of  fluid  into  the  peritoneum,  and  in  some  in- 
stances the  amount  of  this  effusion  is  very  considerable;  enlarge- 
ment of  the  superficial  veins  attests  the  obstruction  to  the  circu- 
lation, and  the  ascites  becomes  the  occasion  of  more  distress  than 
the  original  disease  to  which  it  is  superadded.  Oedema  of  the 
lower  extremities  is  less  frequent  than  in  pregnancy,  probably 
because  the  peculiar  state  of  the  blood  which  fixvors  its  occurrence 
in  the  latter  condition  is  absent.  AVliere  it  exists  it  is  often  con- 
fined to  one  limb,  being  the  direct  result  of  mechanical  pressure. 
This  is  not  invariably  the  case,  however,  for  ovarian  dropsy  is 
sometimes  associated  with  albuminous  urine,  whether  as  the  re- 
sult of  its  accidental  complication  with  granular  disease  of  the 
kidneys,  or  of  congestion  of  those  organs  produced  by  the  pres- 
sure ol"the  tumor,  I  do  not  feel  myself  able  to  determine. 

While  the  enlarging  tumor  thus  tends  to  trouble  all  the  func- 
tions-of  the  body,  the  patient's  strength  is  further  exhausted  by 
the  determination  to  the  growth  of  a  large  quantity  of  that  blood 
which  ought  to  minister  to  the  general  nutrition  of  the  body.  Nor 
is  this  all ;  but  a  state  of  cachexia,  the  consequence  and  the  evi- 
dence of  the  deteriorated  condition  of  the  blood,  occurs  frequently 
in  the  course  of  this,  as  of  other  forms  of  malignant  disease,  with 
which,  if  not  actually  identical,  many  tumors  of  the  ovary  are  at 
any  rate  closely  allied.  In  the  simple  ovarian  cysts  it  is  true  that 
this  latter  source  of  suffering  and  of  peril  does  not  exist,  and  the 
prospects  of  the  patient  are  accordingly  far  less  dark  than  in  other 
varieties  of  the  disease.  These  simple  cysts,  too,  as  has  already 
been  mentioned,  now  and  then  remain  stationary  for  many  years, 
life  being  not  at  all  shortened,  scarcely  even  embittered,  by  their 
presence.  Such,  however,  are  exceptional  cases,  and  exceptions 
of  but  rare  occurrence ;  for  generally  the  accumulation  of  fluid 
even  in  a  simple  cyst,  sooner  or  later  necessitates  the  perform- 
ance of  tapping,  while  when  once  done  its  repetition  is  speedily 
required,  and  the  patient  is  thus  worn  out  by  the  frequent  collec- 
tion and  frequent  evacuation  of  the  contents  of  the  cyst.  A  certain 
risk,  too,  of  cyst-inflammation  accompanies  every  tapping,  and  is, 
when  it  occurs,  a  hazard  of  a  very  serious  kind.  The  liability  to 
its  occurrence  appears  to  be  greatest  either  after  the  first  per- 
formance of  the  operation,  or  else  in  the  case  of  patients  who 
have  been  exhausted  by  the  long  continuance  of  the  disease,  and 
the  frequent  repetition  of  the  tapping.  In  much  debilitated  pa- 
tients, especially  in  those  who  are  sufiering  from  malignant  or 

1  Two  drawings  given  by  Dr.  Bright,  loc.  cit.,  pi.  vii,  ix,  are  extremely  instruc- 
tive illustratiuns  ui'  the  manner  in  which  tumors  of  the  ovary  press  on  and  displace 
the  viscera. 


OVARIAN    DISEASE    PROVES    FATAL.  417 

quasi-malignant  forms  of  ovarian  disease,  the  spontaneous  super- 
vention of  cyst-inflammation,  or  of  a  low  form  of  peritonitis,  is  of 
no  very  rare  occurrence,  and  not  infrequently  puts  out  the  lite  whose 
flame  had  burnt  but  flickeringly  for  weeks  or  months  before. 

We  have  now  completed  our  examination  of  the  structure  of 
cystic  tumors  of  the  ovary,  and  have  also  studied  tlie  dilfcrent 
modes  whereby,  in  some  rare  instances,  nature  effects  their  cure, 
as  well  as  those  far  more  numerous  ways  by  which  the  patient  is 
usually  conducted  from  bad  to  worse,  and  the  fatal  issue  is  but  too 
surely  brought  about.  Before  we  proceed  to  the  investigation  of 
the  symptoms  of  these  diseases,  and  to  the  inquiry  as  to  what 
either  medicine  or  surgery  can  do  for  the^  alleviation  or  their 
cure,  there  are  still  some  questions  concerning  their  causes,  and 
the  circumstances  that  favor  their  occurrence,  to  which  we  must 
endeavor  to  furnish  a  reply. 

It  may  be  asked,  when  do  these  aifections  commonly  occur; 
what  is  the  influence  of  the  exercise  of  the  sexual  functions  upon 
their  development ;  whether  does  sterility  or  fecundity  predis})Ose 
to  them;  and  does  a  disordered  state  of  the  uterine  health  com-' 
monly  precede  them ;  or  are  they  as  likely  to  befall  the  person 
whose  health  has  been  previously  good  as  her  who  for  years  has 
been  a  valetudinarian  ?  To  these  inquiries  as  to  the  aaum's  of 
ovarian  dropsy,  it  would  seem  that  very  definite  and  conclusive 
answers  might  be  given,  and  yet,  strangely  enough,  the  replies  are 
most  contradictory.  The  young  and  the  aged,  the  single  and  the 
married,  the  sterile  and  the  mother  of  many  children,  the  robust 
and  she  whose  uterine  functions  have  been  performed  with  pain 
and  difliculty,  have  all  in  turn  been  asserted  to  be  specially  liable 
to  the  occurrence  of  ovarian  disease. 

With  reference  to  the  age  of  patients  in  whom  the  disease 
occurs,  there  seems  to  be  no  period  of  life  that  enjoys  an  absolute 
immunity  from  it;  though  it  is  of  extreme  rarity  before  puberty, 
and  its  commencement  after  the  cessation  of  the  menstrual  func- 
tion, though  far  less  uncommon,  is  certainly  unusual.  Professor 
Kiwisch  mentions^  a  preparation  of  cystic  disease  of  the  ovary  in 
a  child  only  a  year  old  in  the  museum  of  Prague,  and  refers  to  a 
similar  one  at  Wiirzburg,  in  which  the  affection  involved  both 
ovaries  in  the  foetus.  lie  states,  however,  that  fourteen  years  is 
the  earliest  age  at  which  he  himself  had  observed  it;  and  a  girl 
died  in  St.  Bartholomew's  Hospital,  under  the  care  of  Dr.  lUir- 
rows,  from  malignant  disease  of  the  ovaries,  with  cyst-formation 
in  their  substance,  who  had  not  attained  her  fitteenth  year.  One 
of  my  patients  died  of  rupture  of  the  cyst  when  in  her  sixteenth 
year,  and  the  enlargement  of  her  abdomen,  which  was  very  con- 
siderable at  her  death,  was  alleged  to  have  been  first  observed 
when  she  was  thirteen  years  old — menstruation  not  having  occur- 
red till  the  age  of  fourteen  years  and  six  months.  In  another  of 
my  patients  the  disease  began  in  her  seventeenth  year,  menstrua- 

•  Oj).  cif.,  vol.  ii,  p.  70,  ?  36. 
27 


418  CAUSES    PREDISPOSING 

tion  having  occurred  once  at  the  age  of  fifteen  and  a  half;  "but  it 
did  not  reappear  till  after  she  was  tapped  at  the  age  of  eighteen. 
These,  however,  are  exceptional  occurrences,  and  in  nearly  half 
of  all  cases  of  ovarian  dropsy  the  commencement  of  the  disease 
dates  from  hetween  the  asres  of  thirty  and  forty. 

This  result,  at  least,  is  what  I  arrive  at  from  a  comparison  of  94 
cases  of  my  own  with  97  of  Scanzoni's,^  which  are  thrown  into 
the  following  table.  I  employ  Scanzoni's  figures  in  preference  to 
those  of  any  other  writer,  because  he  alone  has  taken  as  its  basis 
the  ages  at  which  the  first  symptoms  of  the  disease  appeared, 
while  many  writers  have  constructed  their  tables  according  to  the 
age  at  which  the  pati|^its  fii'st  came  under  their  observation. 

Tables  showing  the  Age  at  which,  in  191  Women,  the  symptoms  of 
Ovarian  Dropsy  ivere  fir^t  "perceived. 

Author's  Scanzoni's  Tot^l  ^^'^  **  ^'"^  Proportion  per  cent, 

cases.  Cases.  '   '  symptoms.  at  different  ages. 

17  5  22  from  13' to  25  years,  11.5 

15  12  27  "  25  "  30  "  14.1 

15  21  36  "  30  "  35  "  18.8 

23  82  55  "  35  "  40  "  28.7 

11  14  25  •'  40  "  45  "  13.0 

8  6  14  «'  45  "  50  "  7.3 

3  2  5  ."  50  "  55  "  2.0 

2  5  7  "  55  "  60  "  3.6 

94         97  191 

The  next  question  concerns  the  influence  of  the  exercise  of  the 
sexual  functions  in  predisposing  to  the  disease — an  influence  which 
you  may  remember  was  ver}^  decided  in  the  case  of  uterine  cancer, 
since  only  3  out  of  168  patients  aft'ected  by  it  were  single  women, 
and  only  13  out  of  the  165  who  had  been  married  were  sterile. 
Of  94  cases  of  ovarian  disease,  however,  24  occurred  in  single 
women,  13  in  widows,  and  57  in  the  married — a  statement  which 
refers  to  their  condition  at  the  time  when  the  disease  commenced. 
This  proportion  is  not  very  materially  altered  by  the  employment 
of  higher  numbers,  since,  adding  to  my  own  cases  those  collected 
by  ]\Ir.  Lee  and  those  observed  by  Scanzoui,^  we  obtain  the  follow- 
ing results : 

Single  women, 94,  or  28.7  per  cent. 

Widows, 31,  "      9.4        " 

Married  women, 202,  "    61.7       " 

327 

or,  in  other  words,  considerably  more  than  a  third  of  all  cases  of 
ovarian  disease  began  at  a  time  when  the  sexual  functions  were 
not  in  active  exercise ;  and  more  than  a  fourth  occurred  in  women 
in  whom  those  functions  had  never  been  exerted  at  all. 

1  Op.  cit,  p.  365. 

*  Op.  cit.,  p.  365.  I  have  included  in  this  list  of  married  women,  seven,  who, 
though  single,  had  given  birth  to  one  or  more  children. 


TO    OVARIAN    DROPSY.  419 

That  tlie  exercise  of  the  sexual  functions  does  not  predispose  to 
ovarian  disease,  but  that,  on  the  contrary,  some  connection  sub- 
sists between  their  imperfect  performance  and  the  development 
of  this  aftection,  is  evident  from  the  low  rate  of  fecundity  among 
married  women  in  whom  ovarian  dropsy  occurs.  Of  70  of  my 
patients,  either  married  or  widows,  there  were  26  sterile ;  and  of 
Scanzoni's  52  cases,  18  who  had  likewise  never  been  pregnant; 
or  in  other  words,  in  44  of  122  women  who  became  the  subjects 
of  ovarian  dropsy,  or  in  36  per  cent.,  marriage  had  never  been 
followed  by  conception,  while  among  my  patients  generally  at  St. 
Bartholomew's  IIosj)ital  the  proportion  of  sterile  marriages  was 
only  11.7  per  cent.  Even  those  marriages,  too,  that  were  followed 
by  conception  showed  less  than  the  average  fecundity;  for  of  my 
70  cases,  the  44  in  which  the  women  were  not  sterile  yielded  otdy 
172  pregnancies;  of  these  129  terminated  at  the  full  time,  43 
ended  in  miscarriage.  These  numbers  yield  an  average  of  3.9 
pregnancies  to  each  fruitful  marriage,  or  little  more  than  half  the 
number  which  occurred  in  persons  in  whom  cancer  of  tlie  womb 
took  place.  It  may  perhaps  as  well  be  added,  that  in  14  of  the 
total  33  cases  pregnancy  occurred  but  once,  and  terminated  in  3 
instances  prematurely,  in  the  other  11  at  the  full  period  of  gestation. 

One  question  still  requires  an  answer — namely,  what  connection, 
if  any,  subsists  between  the  ordinary  state  of  a  2:>afient's  ntrrine 
health,  and  the  subsequent  development  of  ovarian  disease?  Now 
nothing  can  seem  more  probable  than  that  she  who  has  men- 
struated irregularly,  painfully,  or  scantily,  shall  be  more  liable  to 
suffer  afterwards  from  diseases  of  the  ovaries  than  the  person 
whose  menstruation  has  always  gone  on  quite  regularly.  This, 
too,  appears  from  Scanzoni's  statement  really  to  be  the  case ; 
though  my  own  observations  do  not  corroborate  his  assertion, 
and  probably  neither  his  facts  nor  mine  are  sufficiently  numerous 
to  decide  the  question. 

Of  my  own  94  cases,  there  were  72  in  which  the  ordinary  uterine 
health  was  quite  good;  3  had  had  puerperal  inflammation,  but  had 
quite  recovered  from  its  eftects;  1  was  still  weak  from  hemorrhage 
after  delivery;  in  8  menstruation  was  always  painful;  in  5  men- 
struation was  always  scanty;  in  3  habituall}'  irregular;  1  was 
chlorotic,  and  had  bad  uterine  health  in  all  respects;  i  had  suffered 
for  years  from  great  hypertrophy  of  the  neck  of  the  womb,  and 
much  consequent  discomfort. 

On  the  other  hand,  Scanzoni  says  that  there  were  but  20  of  his 
57  cases  in  which  menstruation  was  always  healthy;  while  19 
patients  had  suffered  more  or  less  from  chlorosis,  12  from  dys- 
menorrhoca,  5  had  always  menstruated  very  profusely,  and  1  })a- 
tient,  in  whom  ovarian  disease  came  on  in  her  forty-first  year,  had 
never  menstruated  at  all.  Be  the  truth  concerning  this  matter 
what  it  may,  I  cannot  but  think  that  Scanzoni's  figures  overstate 
the  frequency  of  menstrual  disorder,  as  a  precursor  of  ovarian 
disease,  as  much  as  mine  perhaps  err  on  the  opposite  side. 

We  find  that  in  the  case  of  most  diseases,  our  patients  like  to 


420  EXCITING    CAUSES    OF    OVARIAN    DKOPSY. 

assign  some  cause  for  the  commencement  of  tlieir  ailment,  a  cause 
often  indeed  quite  fanciful,  sometimes  absurd.  It  is  so  in  the  case 
of  ovarian  diseases,  while  if  all  mere  phantasies  are  rejected,  the 
instances  will  turn  out  to  be  comparatively  few  and  excei^tional 
in  which  any  plausible  ground  can  be  assigned  for  the  beginning 
of  the  affection.'  In  21  of  Scanzoni's  97  cases,  and  in  18  of  my  94, 
or  in  39  out  of  191  instances,  the  following  were  with  some  prob- 
ability alleged  as  the  exciting  causes  of  ovarian  dropsy : 

Bogan  within  a  year  after  marriage,     ...  in  6 

Came  on  during  pregnancy, "  2 

Followed  not  long  after  delivery,     ....  "15 

Succeeded  to  abortion, "  4 

"  metritis  from  cold, "  3 

"  suppressed  menses  from  cold,  .  "  2 
"  violent  blow  on  the  hypogastrium,  "  1 
"  violent  blows  on  the  pelvis,  .  "  2 
"  strains,  or  over-exertion,  .  .  "  3 
Occurred  simultaneously  with  ascites  and  ana- 
sarca from  exposure  to  cold, "  1 

39 

From  all  these  facts,  then,  we  may  conclude  that  the  immedi- 
ately exciting  cause  of  ovarian  dropsy,  when  any  cause  can  be 
assigned  for  it,  is  usually  connected  with  some  disorder  of  the 
uterine  functions,  or  with  the  recent  excitement  of  their  highest 
forms  of  activity.  Nevertheless,  too  wide  an  inference  must  not 
be  drawn  Irom  this  fact,  since  in  the  great  majority  of  instances 
the  disease  comes  on  independently  of  any  cause  to  which  it  can 
be  reasonably  attributed;  while  further,  it  occurs  in  the  unmar- 
ried ortener  than  most  other  organic  diseases  of  the  sexual  organs; 
and  the  married  who  suffer  from  it  are  remarkable  for  their  low 
rate  of  fecundity,  and  for  the  frequency  among  them  of  absolute 
sterility. 

In  the  next  Lecture  we  shall  leave  these  incomplete  and  incon- 
clusive details  for  the  more  important  practical  inquiry  into  the 
symptoms  and  diagnosis  of  tumors  of  the  ovary. 

'  Of  36  instances  collected  by  Mr.  Lee,  op.  cit.,  p.  118,  there  wore  28  in  which 
the  alleged  causes  had  reference  to  the  uterine  functions,  being  in  -3  marriage,  in  9 
labor,  in  2  abortion,  in  7  sudden  suppression  of  the  menses,  in  2  cessation  of  men- 
struation, and  in  3  irregularity  of  its  performance. 


EARLY    SYMPTOMS    OF    OVARIAN    DROPSY.  421 

LECTURE    XXVII. 

OVARIAN  TUMORS   AND  DROPSY. 

Symptoms  of  the  disease  occasionally  absent  in  early  stage:  generally  referable 
to  five  heads — of  functional  disorder  of  ovaries,  pain,  the  etlects  of  pressure, 
cachectic  symptoms,  and  the  symptoms  consequent  on  interference. 

Diagnosis,  its  difficulties;  diagnosis  from  inflammation  of  broad  ligament  and  its 
efl'ects,  from  fibrous  tumors  of  uterus,  misplacement  of  uterus,  ascites,  disten- 
sion of  bladder,  pregnancy,  tumors  of  spleen  or  liver,  &c. 

Note  on  floating  tumors  of  tue  abdomen. 

Many  uterine  ailments  in  their  early  stage  present  a  puzzling 
resemblance  to  each  other.  Pain  and  menstrual  disorder  are 
common  to  most,  and  accompany  as  well  the  slight  as  the  more 
serious  affections,  while  it  is  often  not  until  after  some  time  that 
the  distinctive  features  of  the  disease  show  themselves,  and  enable 
us  to  determine  its  nature,  and  to  estimate  its  importance. 

This  is  especially  true  with  reference  to  ovarian  disease,  which 
at  its  onset  commonly  attracts  but  little  notice,  owing  to  the 
vagueness  of  its  early  si/mptoms :  while  not  infrequently,  just  as  is 
the  case  with  fibrous  tumors  of  the  uterus,  its  existence  is  not  sus- 
pected till  accident  all  at  once  reveals  the  presence  of  a  growth 
of  considerable  size. 

On  a  comparison  of  the  94  cases  on  which  these  observations 
are  chiefly  founded,  it  appears  that  the  first  symptom  of  ovarian 
disease  was — 

Suppression  of  the  menses, 11  cases 

Irregular  menstruation, 5  " 

Scanty  and  painful  menstruation, 1  " 

Profuse  menstruation, 2  " 

Sudden  faintness,  accompanied  by  symptoms  resembling 

those  of  pregnancy,        1  " 

Pain  in  the  abdomen,  more  or  less  distinctly  referred  to 

the  side  where  the  disease  began, 31  " 

Retention  of  urine,  or  difficult  micturition,     ....   10  " 

The  unexpected  discovery  of  a  tumor, 33  " 

94     " 

The  want  of  attention  to  their  own  condition  innilied  in  the 
very  considerable  size  to  which  abdominal  tumors  sometimes  at- 
tain before  they  attract  the  notice  of  patients  is  so  remarkable  as 
to  be  scarcely  credible  if  it  were  not  of  every-day  occurrence.  Not 
very  long  since  I  saw  a  young  lady  in  whom  an  ovarian  cyst  of 
the  size  of  the  adult  head  was  only  accidentally  discovered  incon- 
sequence of  her  suflering  from  a  severe  attack  of  abdomintd  pain 
while  staying  in  the  house  of  a  medical  man.  If  tumors  so  large 
can  escape  notice,  it  is  less  to  be  wondered  at  that  those  of  smaller 
size  should  frequently  be  found  out  only  when  they  become  the 


422  SYMPTOMS    OF    OVARIAN    DROPSY 

seat  of  pain,  or  when  they  cause  inconvenience  by  pressure  on 
surrounding  viscera. 

It  is  not  easy  to  say  on  what  the  frequent  absence  of  symptoms 
in  the  earlier  stage  of  ovarian  dropsy  depends.  The  immunity 
from  suffering  then  is  also  far  from  constant,  and  in  many  instances 
much  more  pain  and  discomfort  are  experienced  while  the  enlarged 
ovary  still  remains  within  the  pelvi<j  cavity,  than  are  felt  subse- 
quently, or  at  least  than  are  experienced  till  its  size  begins  to  in- 
terfere with  the  functions  of  the  abdominal  viscera.  While  in  the 
pelvis  the  large  ovary  presses  on  the  rectum,  the  uterus,  and  the 
bladder,  and  maintains  a  constant  congestion  of  the  pelvic  vessels, 
all  of  which  inconveniences  are  diminished,  or  completely  re- 
moved when  once  it  rises  higher,  and  floats  as  it  were  loosely 
tethered  by  the  ovarian  ligament.  When  pains  are  experienced, 
too,  they  generally  tell  plainly  of  some  cause  seated  within  the 
pelvis.  They  are  usually  of  a  throbbing  or  burning  character, 
referred  chiefly  to  one  or  other  iliac  region,  and  are  liable,  like  all 
ovarian  pains,  to  exacerbation  in  paroxysms.  More  frequently, 
too,  in  this  affection  than  in  any  form  of  uterine  disease,  pain  is 
experienced  extending  down  the  leg  of  the  affected  side,  being 
sometimes  a  mere  numbness  or  sense  of  weariness,  aggravated, 
however,  and  rendered  positive  suffering  by  walking  or  exercise; 
at  other  times  it  is  severe  and  neuralgic  in  character.  Besides  this, 
too,  painful  defecation  and  micturition,  especially  the  latter,  are 
frequent;  and  occasionally  the  necessity  for  the  introduction  of 
the  catheter  is  an  early  symptom  of  the  disease;  though  while  the 
dysuria  often  persists  for  a  considerable  time,  retention  of  urine 
is  a  rare  accident,  and  may  even  not  occur  a  second  time. 

Though  generally  more  severe  than  the  same  class  of  symptoms 
when  they  accompany  fibrous  tumors  of  the  uterus,  they  are  at 
the  same  time  usually  of  shorter  duration,  since  an  ovarian  cyst 
tends  more  certainly,  and  at  an  earlier  period,  to  rise  out  of  the 
pelvic  cavity  than  does  the  fibrous  tumor,  whose  growth  is  slower, 
and  whose  close  connection  with  the  womb  confines  it  longer  to  its 
original  position. 

My  own  observations  do  not  show  such  frequent  disorders  of 
menstruation  as  might  be  expected,  either  among  the  precursors 
of  ovarian  disease,  or  among  its  earlier  symptoms.  Few,  however, 
indeed,  are  the  cases  in  which  the  disease  runs  to  its  fatal  termi- 
nation without  the  uterine  functions  being  altogether  deranged. 
I  have  not  the  data  to  show  the  influence  of  the  disease  from  its 
commencement  to  its  close  in  this  respect.  The  following  table 
represents  the  state  of  94  patients,  in  all  of  whom  the  disease  was 
fully  established ;  but  the  majority  were  only  a  few  weeks  or 
months  under  observation. 

In     7  cases  menstruation  had  ceased  before  the  disease  began. 
"      2       "     disease  began  during  pregnancy. 
"    29       "     menstruation  had  continued  quite  undisturbed. 


IN    ITS    LATER    STAGES.  423 


In  tho.  remaining  56 

Menstruation  was  painful  in  1 

"                 "  profuse  "  9 

"                 "  anticipating"  5 

"                 "  irregular  "  10;  in  5  was  the  first  symptom, 

"                 "  postjioning  "  3  ;  in  1  was  the  first  sVmjitom. 

"                 "  scanty  "  6 

"                 "  suppressed  "  22  ;  in  6  was  the  first  symptom. 

56 

The  general  tendency  of  tlie  disease  then  is  to  impair  the  activity 
of  the  ovarian  functions,  no  doubt  by  the  disorganization  of  their 
tissue.  Hence  the  persistence  of  menstruation  is  always  a  favor- 
able sign  in  cases  of  ovarian  dropsy,  warranting  the  hope  that 
the  disease  is  simple  in  kind,  and  that  one  ovar}^  only  is  involved. 
Complete  amenorrhoja,  liowever,  is  more  to  be  dreaded  as  an  un- 
favorable sign  than  is  even  tolerably  regular  menstruation  to  be 
hailed  as  evidence  of  the  simpler  forms  of  disease,  or  of  its  being 
limited  to  one  side. 

It  is  not  possi])le  to  give  any  general  description  of  the  symp- 
toms which  attend  the  later  stages  of  ovarian  dropsy.  They  are 
modified  by  very  many  causes,  and  diiier  according  to  the  nature 
of  the  tumor,  the  rate  of  its  increase,  the  age  of  the  patient,  and 
even  her  civil  state,  and  general  condition.  They  may,  however, 
be  referred  to  some  of  the  five  following  heads,  which  have  already 
been  briefiy  touched  upon  when  I  was  endeavoring  in  the  last 
lecture  to  point  out  the  various  modes  in  which  the  fatal  issue  of 
ovarian  dropsy  is  prepared  for  or  actually  brought  about. 

1st.  There  are  the  various  evidences  of  derangement  of  the 
function  of  the  ovaries,  showing  themselves  in  ditferent  forms  of 
menstrual  disorder,  of  which  the  irregularity,  or  the  total  suppres- 
sion of  the  discharge  are  the  most  common  ;  its  over- frequent,  or 
too  profuse  occurrence  are  the  rarest.  Menorrhagia,  hoAvever, 
does  now  and  then  for  a  season  accompany  ovarian  dropsy,  so 
that  we  cannot  place  unqualified  reliance  on  the  state  of  the  men- 
strual function  as  enabling  us  to  discriminate  between  uterine  and 
ovarian  tumors. 

2d.  Pain  and  other  symptoms  are  experienced  indicative  of 
changes  in  the  tumor  itself.  In  sini[)le  cysts,  the  degree  of  ful- 
ness and  tension  of  the  cyst  seems  in  great  measure  to  determine 
the  presence  or  absence  of  pain.  Variations  in  this  respect  often 
take  place  with  great  rapidity,  and  increased  j)ain  will  be  found 
almost  invariably  associated  with  increased  tension,  and  an  abate- 
ment of  suflering  with  a  fiaccid  state  of  the  cyst.  The  occurrence 
of  actual  inflammation  is  almost  always  accompanied  with  teinlor- 
ness  of  the  tumor,  though,  unless  the  peritoneal  surface  is  affected, 
there  is  not  usually  much  pain  except  on  jiressure.  Vague  con- 
stitutional disturbance  usually  attends  this  jn-ocess,  and  though  it 
is  seldom  very  well  marked,  yet  indefinite  febrile  jittacks,  shiver- 
ing, loss  of  flesh,  and  heetic,  may  generally  be  regarded  as  indieative 
of  this  occurrence,  and  the  more  certainly  i»rovided  the  abdominal 


424  SYMPTOMS    OF    THE    LATER    STAGES 

tumor  is  found  to  be  tender  on  pressure.  The  malignant  forms 
of  ovarian  tumor  are  often  associated  with  pain  during  their 
growth,  quite  independently  of  tension  of  their  walls,  or  of  any 
attack  of  inflammation.  This,  however,  is  by  no  means  constant, 
and  no  inference  as  to  the  simple  character  of  the  disease  can  be 
dra^vn  from  the  painlessness  of  its  development. 

3d.  With  the  increase  of  the  growth  various  disorders  are  pro- 
duced by  its  pressure  on  the  different  viscera,  and  a  class  of  symp- 
toms appear,  whose  causes  I  dwelt  on  fully  in  the  course  of  the 
last  lecture. 

Difficult  breathing,  impaired  digestion,  obstinate  constipation, 
frequent  and  painful  micturition,  diminished  secretion  of  urine 
and  the  effusion  of  blood  into  the  abdominal  cavity,  are  but  so 
many  different  results  of  this  mechanical  pressure.  The  difficulty 
in  micturition,  however,  that  occurs  in  the  more  advanced  stage 
of  the  disease  is  produced  in  a  different  manner  from  that  which 
accompanies  its  commencement.  AVhilc  the  tumor  is  still  within 
the  pelvic  cavity,  it  interferes  with  micturition  by  pressing  directly 
against  the  bladder;  afterwards,  as  it  rises  out  of  the  pelvis,  it 
drags  the  uterus  and  bladder  upwards,  and  thus  interferes  with 
the  function  of  the  latter  organ,  while  the  presence  of  a  portion  of 
the  outgrowth  behind  the  bladder  in  most  cases  prevents  its  dis- 
tension in  the  antero-posterior  direction.  Scanzoni  mentions  also 
another  occasional  result  of  the  pressure  of  the  tumor  on  the  under 
part  of  the  bladder.'  He  states  that  it  sometimes  prevents  the 
passage  of  the  urine  from  the  ureters,  and  thus  produces  great 
distension  both  of  them  and  of  the  pelvis  of  the  kidneys,  and  in 
illustration  of  this  relates  the  case  of  a  "patient  who  was  ta[)ped 
twenty-one  times  in  the  course  of  three  years,  which  operation, 
during  the  last  year  other  life,  was  rendered  necessary  chiefly  by 
the  circumstance  that  the  rapid  accumulation  of  fluid  in  the  tumor 
was  always  accompanied  by  complete  retention  of  urine,  which 
could  not  be  relieved  by  the  catheter,  since  the  pressure  of  the 
tumor  prevented  the  escape  of  the  urine  from  the  ureters  into  the 
bladder.  For  the  first  few  days  after  each  tapping  the  function 
of  the  bladder  was  undisturbed,  but  by  degrees  the  flow  of  urine 
became  more  and  more  scanty,  and  in  the  course  of  five  or  six 
weeks  complete  retention  of  urine  was  once  more  produced.  On 
examination  of  the  body  after  death,  a  cysto-sarcomatous  tumor 
was  discovered,  twice  the  size  of  the  adult  head,  the  lower,  solid 
part  of  which  pressed  on  the  neck  of  the  bladder,  and  had  pro- 
duced, by  the  obstacle  to  the  outflow  of  the  urine,  so  great  a  dila- 
tation of  both  ureters  that  the  right  was  two  inches,  the  left  an 
inch  and  a  half  in  diameter." 

The  pressure  on  the  stomach  sometimes  causes  a  serious  impedi- 
ment to  the  patient's  taking  food,  since  not  only  does  the  organ 
become  unable  to  retain  more  than  extremely  small  quantities  at 
a  time,  but  in  some  instances  obstinate  vomiting  occurs,  which  no 


Op.  cit,  p.  424. 


( 


OF    OVARIAX    DROPSY.  425 

medicine  can  in  the  least  degree  relieve,  and  which  is  arrested  only 
by  tapping  the  cyst,  and  thus  removing  the  pressure. 

Still  more  distressing  sym])tonis  sometimes  follow  the  compres- 
sion of  the  rectum.  ISTot  only  is  most  obstinate  constipation  thus 
induced,  but  even  the  escape  of  flatus  is  in  some  instances  pre- 
vented :  the  whole  colon  becomes  distended  by  it  to  the  thickness 
of  the  arm  ;  and  every  now  and  then  violent  attacks  of  colic  pains 
come  on,  during  which  the  movements  of  the  bowels  are  distinctly 
visible  through  the  thinned  abdominal  parietes,  and,  as  in  ileus  or 
in  strangulated  hernia,  stercoraccous  vomiting  adtls  from  time  to 
time  to  the  patient's  sufl'erings. 

4th.  To  this  class  belong  a  large  array  of  s3^mptoms  of  the 
cachectic  kind,  due  in  some  instances  to  the  nature  of  the  disease 
of  the  ovaries;  in  others,  to  the  mere  diversion  to  the  tumor  of  a 
large  quantity  of  blood  which  ought  to  minister  to  the  general  ne- 
cessities of  the  body.  They  are  symptoms  of  the  same  kind  as  we 
see  towards  the  close  of  every  lingering  disease,  betokening  the 
gradual  failure,  first  of  one  power,  then  of  another;  the  flickering 
of  the  taper,  which,  as  all  can  see,  must  soon  go  out.  The  appetite 
becomes  more  and  more  capricious,  and  at  last  no  ingenuity  of 
culinary  skill  can  tempt  it,  while  digestion  fails  even  more  rajtidly, 
and  the  wasting  l)ody  tells  but  too  plainly  how  the  little  food  nour- 
ishes still  less  and  less.  The  pulse  grow's  feebler,  and  the  strength 
diminishes  everyday;  and  one  by  one  each  customary  exertion 
is  abandoned:  at  first  the  efforts  ntade  for  the  sake  of  the  change 
which  the  sick  so  crave  for  are  given  up  ;  then  those  for  cleanli- 
ness, and  lastl}^  those  for  comfort;  till  at  length  one  position  is 
maintained  all  da}^  long  in  spite  of  the  cracking  of  the  tender 
skin,  it  sufficing  for  the  patient  if  in  that  respiration  can  go  on 
quietly,  and  she  can  suffer  undisturbed.  "Weariness  drives  away 
sleep,  or  sleep  brings  no  refreshing.  The  mind  alone,  amid  the 
general  decay,  remains  undisturljcd;  but  it  is  not  cheered  by  those 
illusory  hopes  which  gild,  though  with  a  false  brightness,  the  decline 
of  the  consumjitive;  for  step  by  stcji  death  is  felt  to  be  advancing; 
the  patient  watches  his  approach  as  keenly  as  we,  often  Avith  acuter 
jierception  of  his  nearness.  We  come  to  the  sick-chamber  day  by 
day  to  be  idle  spectators  of  a  sad  ceremony,  and  leave  it  humbled 
by  the  consciousness  of  the  narrow  limits  which  circumscribe  the 
resources  of  our  art. 

5th.  May  here  be  reckoned  all  those  incidents  which  are  insepa- 
rable from  every  attempt  at  alleviation  or  at  cure.  The  exhausti(»n 
which  follows  after  repeated  tappings,  the  c^'st-inflanmiation  which 
sometimes  succeeds  to  its  first  performance,  the  hemorrhage  from 
vessels  divided  in  the  extirpation  of  the  tumor,  or  the  more  fre- 
quent, and  therefore  more  serious  attacks  of  peritonitis  that  are 
induced  even  l)y  attempts  at  its  removal,  all  belong  to  this  category. 
Tlieir  study,  however,  will  find  its  fittest  place  when  we  come  to 
consider  the  treatment  of  the  different  forms  of  the  disease,  and 
the  comparative  dangers  either  of  letting  it  alone,  or  of  endeavor- 
ing by  one  or  other  of  the  numerous  means  which  have  been  de- 


426  DIAGNOSIS    OF 

vised,  either  to  delay  its  progress,  to  mitigate  its  evils,  or  to  accom- 
plish its  entire  removal. 

But  before  we  pass  to  this  subject,  there  comes  the  inquiry  as 
to  the  diagnosis  of  ovarian  tumors — an  inquiry  the  importance  of 
which  it  is  impossible  to  overrate,  while,  though  sometimes  at- 
tended by  no  difficulty,  it  is  at  others  exceedingly  obscure,  and 
calls  for  large  experience  and  well-schooled  observation  to  return 
a  correct  reply. 

The  difficulties  which  we  encounter  in  the  diagnosis  of  tumors 
of  the  ovary  vary  according  to  the  size  of  the  growth,  and  the 
situation  that  it  occupies.  So  long  as  it  remains  principally  within 
the  cavity  of  the  pelvis,  it  for  the  most  part  yields  but  an  indistinct 
sense  of  fluctuation,  even  though  its  contents  should  be  entirely 
fluid,  and  it  may  then  be  hard  to  distinguish  between  it  and  the 
results  of  inflammation  of  the  broad  ligament,  or  between  it  and 
a  fibrous  tumor  of  the  womb,  or  the  retroflected  uterus  itself,  espe- 
cially if  the  organ  is  enlarged  by  pregnancy.  When  the  grov/tli 
has  ascended  into  the  abdomen,  the  distended  bladder,  the  preg- 
nant uterus,  the  enlargement  produced  by  ascites,  by  tumors  of 
the  uterus  itself,  or  by  tumors  of  other  organs,  as  the  liver,  spleen, 
omentum,  or  mesentery,  present  so  many  separate  sources  of  error 
against  which  we  need  to  be  on  our  guard ;  while,  last  of  all,  the 
caution  is  not  supei'fluous  which  warns  us  to  be  on  the  watch 
against  imaginary  tumors  such  as  are  produced  by  flatus  in  the 
intestines,  or  by  fat  in  the  integuments,  or  loading  the  omentum, 
or  by  fieces  in  the  large  intestine,  or  against  those  still  more  un- 
real swellings  which  have  no  existence  at  all  save  in  the  disordered 
fancy  of  the  patient. 

It  sometimes  happens  that  the  earlier  stages  of  ovarian  dropsy 
are  accompanied  by  a  good  deal  both  of  general  febrile  disturbance 
and  of  local  suflering.  In  such  cases  doubt  may  for  a  time  be 
entertained  as  to  whether  a  swelling  which  is  discovered  by  the 
side  of  the  uterus  is  the  result  of  inflammation,  or  whether  a  more 
serious  view  must  be  taken  of  its  nature.  If  the  disease  be  ovarian, 
it  will  generally  be  found  on  close  investigation  that  some  slight 
discomfort,  referred  to  the  aflected  side,  had  for  a  considerable 
time  preceded  the  more  acute  symptoms,  or  that  those  symptoms 
themselves  had  been  of  longer  duration  than  are  commonly  such 
as  betoken  injiammation  of  the  broad  ligament.  At  the  same  time, 
however,  it  must  be  borne  in  mind  that  an  attack  of  inflamnuition 
is  sometimes  the  first  evidence  of  the  presence  of  ovarian  tumor, 
and  that  this  is  especially  the  case  with  hair  and  fat  cysts  of  the 
ovary.  Still  even  then  the  inflammation  does  not  in  general  ex- 
tend to  the  adjacent  tissues,  so  that  the  ovarian  tumor  is  very  often 
still  movable ;  or  if  it  be  pressed  so  closely  between  the  uterus 
and  the  pelvic  wall  as  to  have  lost  this  characteristic,  yet  we  miss 
that  thickening  and  induration  of  the  roof  of  the  vagina  which 
are  such  constant  attendants  on  inflammation  of  the  broad  liga- 
ment, and  of  parts  therewith  connected.  The  tumor,  too,  whether 
felt  per  vaginam,  or  with  the  hand  over  the  ramus  of  the  pubes, 


OVARIAN    DROPSY.  427 

presents  a  much  more  definite  outline  than  is  yielded  by  the 
swelling  formed  by  the  inflamed  broad  ligament ;  while,  lastly,  in 
many  instances  the  uterine  sound  enables  us  to  isolate  the  womb 
from  the  tumor  by  its  side.  Even  when  at  first  there  is  most 
room  for  doubt,  observation  continued  for  a  comparatively  short 
time  almost  always  dispels  the  uncertainty.  Often  the  inflarjima- 
tion  attaoks  the  side  opposite  to  that  first  aft'ected,  while  it  is  rare 
for  both  ovaries  to  be  involved  within  so  short  a  time  of  each 
other.  But  even  though  this  should  not  occur,  the  inflammation 
will  nearly  certainly  issue  in  suppuration  and  the  discharge  of 
matter,  though  perhaps  by  no  perceptible  channel.  The  swelling 
will  then  diminish,  though  for  a  time  possibly  increasing  in  hard- 
ness, till  at  length  it  slowly  disappears;  while  the  ovarian  tumor, 
on  the  contrary,  will  increase,  and  with  its  growing  bulk  the  pres- 
ence of  fluid  within  it  will  become  more  and  more  perceptible. 

The  distinction  between  fibrous  tumors  of  the  uterus  and  tumor 
of  the  ovary  is  far  from  being  as  easy  as  might  beforehand  be 
anticipated,  especially  when  the  tumor  grows  from  the  posterior 
uterine  wall.  The  facts  that  fibrous  tumors  are  seldom  developed 
at  as  early  an  age  as  tumors  of  the  ovary,  that  they  are  seldom 
solitary,  and  that  they  are  usually  accompanied  by  menorrhagia, 
are  always  worth  bearing  in  mind,  though  far  enough  from  being 
conclusive  in  any  doubtful  case.  But,  besides,  their  surface  is 
often  uneven  or  nodulated;  they  present  a  greater  degree  of  hard- 
ness than  an  ovarian  cyst,  though  it  must  not  be  forgotten  that 
when  small  and  tense  the  cyst  may  yield  no  distinct  evidence  of 
fluctuation,  while  a  large  and  rapidly  growing  fibrous  tumor  may, 
when  felt  through  the  abdominal  walls,  present  a  sense  of  elasticity 
which  gives  it  a  most  deceptive  resemblance  to  an  ovarian  cyst. 
I  know  of  one  instance  in  which  this  resemblance  betrayed  two 
very  experienced  surgeons  into  an  operation  for  the  removal  of  a 
supposed  ovarian  cyst,  but  who  discovered,  when  too  late,  that  the 
tumor  was  a  very  large  fibrous  growth  from  the  outer  surface  of 
the  uterus.  The  opposite  error  I  have  both  seen  committed  by 
others,  and  have  fallen  into  it  myself,  in  cases  where  a  small  thin- 
walled  ovarian  cyst  was  still  lying  within  the  pelvic  cavity,  and 
consequently  close  to  the  uterus,  while  the  pressure  from  above 
and  around  it  sufficed  not  only  to  destroy  all  sense  of  fluctuation, 
but  even  to  take  aw'ay  from  it  that  feeling  of  elasticity  which  is  so 
rarely  absent  from  sacs  containing  fluid.  The  circumstance  of  the 
tumor  being  felt  at  both  sides  of  the  pelvis,  on  which  stress  hjis 
been  laid  by  some  writers  as  indicative  of  fibrous  tumors  of  the 
uterus,  is  in  reality  of  no  great  worth,  since,  as  stated  in  the  last 
lecture,  both  ovaries  are  involved  in  the  disease  in  altout  a  third  of 
all  cases.  Fibrous  tumors  not  infrequently  somewhat  retrovert 
the  womb,  while  tumors  of  the  ovary  do  not  produce  that  eflect, 
but  merely  drive  it  forwards  and  to  one  side.  "VVe  are  very  apt, 
however,  to  be  misled  with  reference  to  this  point  if  we  examine 
the  patient  in  the  ordinary  jiosition  on  her  lett  side,  since  the 
weight  of  the  tumor  will  be  likel}'  to  drag  or  to  push  the  womb 


428  DIAG]|^SIS    OF 

towards  tlie  side  on  wliicli  the  woman  lies;  and  on  this  account, 
the  examination  with  the  view  of  ascertaining  this  fact  should  be 
made  w^ith  the  patient  lying  on  her  back.  The  sound,  too,  often 
helps  to  clear  up  doubt,  sometimes  by  distinctly  isolating  the 
uterus  from  the  ovarian  tumor,  in  other  cases  by  ascertaining  the 
cavity  of  the  womb  not  to  be  elongated,  and  thus  leading  to  the 
conclusion  that  the  growth  does  not  spring  from  its  walls.  Valu- 
able, however,  as  the  evidence  thus  obtained  unquestionably  is, 
two  circumstances  detract  from  its  worth.  Elongation  of  the 
uterine  cavity  is  met  with  in  cases  of  ovarian  disease  either  by  the 
tumor  as  it  rises  out  of  the  pelvis  dragging  out  the  corresponding 
horn  of  the  uterus,  instead  of  merely  lengthening  the  ligaments 
of  that  side,  or  as  the  result  of  adhesions  having  formed  between 
the  uterus  and  the  tumor,  when  the  cervix  becomes  of  necessity 
greatly  stretched  by  the  ra])id  increase  of  the  growth.  In  both  of 
these  cases  the  measurement  by  means  of  the  sound  would  suggest 
an  incorrect  conclusion;  and  hence  we  are  justified  in  attaching 
greater  weight  to  the  evidence  which  the  small  uterine  cavity 
affords  of  the  disease  being  ovarian  than  to  that  wliich  the  large 
uterine  cavity  yields  of  the  disease  being  seated  in  the  womb. 

The  grooved  needle  ought  perhaps  to  be  mentioned  as  assisting 
in  doubtful  cases,  by  attbrding  proof  either  of  the  solidity  of  a 
tumor  or  of  the  presence  of  fluid  within  it.  The  failure  to  dis- 
cover fluid  in  a  tumor  does  not,  however,  by  any  means  disprove 
its  being  ovarian;  while  further,  with  reference  to  this  aid  to 
diagnosis,  I  would  add  that  its  use  is  not  always  harmless,  but 
that  symptoms  of  serious  inflammation  are  sometimes  excited 
even  by  the  simple  puncture  wdth  the  needle  of  a  tumor  wliich 
had  not  seemed  to  be  endowed  with  any  high  degree  of  sensibility. 

The  tumor  formed  by  the  retroverted  or  retrojleeted  uterus  is 
scarcely  likely  to  be  mistaken  for  an  ovarian  tumor.  In  the  first 
place,  as  has  just  been  mentioned,  the  tumor  of  the  ovary  does 
not  alter  the  direction  of  the  os  uteri,  but  merely  carries  it  for- 
wards towards  the  anterior  pelvic  wall,  while,  in  the  next  place, 
the  small  size,  the  solidity,  and  the  comparatively  slight  mobility 
of  the  retroflected  fundus  of  the  uterus,  and  the  direct  transition 
of  the  cervix  uteri  into  its  substance,  sufiice,  independently  even 
of  the  information  aflbrded  by  the  sound,  to  preserve  us  from 
error.  In  one  instance,  however,  where  retroflection  of  the  uterus 
had  persisted  down  to  the  end  of  the  sixth  month  of  pregnancy, 
I  fell  into  the  error  of  mistaking  the  tumor  for  ovarian  disease. 
There  were,  it  is  true,  many  circumstances  which  in  this  case 
tended  to  throw  one  off  one's  guard;  but  I  would  remind  you, 
first,  that  just  such  exceptional  cases  are  those  for  which  hal)its  of 
observation  are  to  be  cultivated,  and  diagnostic  skill  is  to  be  ac- 
quired; and  second,  that  in  every  instance  of  doubtful  pelvic  or 
abdominal  tumor,  before  we  attempt  to  determine  what  it  is,  we 
must  first  thoroughly  satisfy  ourselves  that  it  is  not  the  result  of 
pregnancy. 

When  the  tumor  has  increased  in  size,  so  as  to  occupy  the  ab- 


OVARIAN  ^RO  PS  Y.  429 

dominal  cavity,  there  are  other  affections  with  which  it  may  be 
confounded.  In  many  of"  these  cases,  too,  we  are  compelled  to 
jndge  exclusively  from  what  comes  under  our  personal  observa- 
tion, for  the  patient  is  often  unable  to  give  other  than  a  most 
imperfect  account  of  her  previous  condition,  or  of  the  symptoms 
which  attended  the  development  of  her  disease.  In  the  case  of 
all  al)dominal  tumors  wliose  nature  is  at  all  obscure,  it  is  there- 
fore prudent  to  take  certain  precautions  before  we  attempt  to 
establish  their  diagnosis.  It  is  always  useful  to  keep  the  ])atient 
in  bed  for  twenty-four  hours;  and  if  the  abdominal  distension  is 
at  all  considerable,  to  apply  a  bandage  lightly,  as  well  as  to  take 
care  that  the  bowels  are  freely  relieved  some  hours  before  our 
examination  is  made.  The  difference  between  the  morning  and 
afternoon  measurement  of  the  abdomen  in  the  case  of  a  person 
following  her  ordinary  pursuits  is  often  as  much  as  an  inch  and  a 
half;  and  this  increase  in  the  after  part  of  the  day  appears  to  be 
almost  entirely  due  to  the  presence  of  flatus  in  the  intestines.  On 
the  other  hand,  the  good  effects  of  a  day's  stay  in  bed  are  often 
very  striking  in  the  diminution  of  abdominal  distension,  and  the 
consequently  increased  fncility  with  which  the  relations  of  any 
tumor  are  examined,  while,  at  the  same  time,  the  tenderness  of 
the  abdominal  walls  is  much  lessened,  and  they  become  far  more 
tolerant  than  they  otherwise  would  be  of  the  pressure  of  the  hand. 
The  general  tendency  of  ovarian  tumors,  as  they  increase  in 
size,  is  to  yield  with  more  and  more  distinctness  the  sense  of  fluctu- 
ation ;  and  many  growths  which,  when  small,  had  seemed  to  be 
solid,  become  evidently,  in  the  course  of  time,  large  simple  cysts 
with  fluid  contents.  This  change  is  brought  about  either  by  the 
tension  of  the  cyst  diminishing  as  it  grows  larger,  in  consequence 
of  which  fluctuation  becomes  more  manifest ;  or  by  the  removal 
of  the  septa  which  had  previously  divided  it  into  many  chainliers; 
or  lastly,  by  the  growth  of  one  cyst  at  the  expense  of  the  others, 
which  remain  with  whatever  solid  matter  enters  into  tlie  composi- 
tion of  the  tumor,  at  its  lower  part,  near  to  its  pedicle,  where  they 
cannot  readily  be  detected.  It  is  due  to  the  influence  of  some  or 
all  of  these  causes  that  we  occasionally  find  the  abdomen  so  much 
enlarged,  and  the  fluctuation  in  all  directions  so  uniformly  distinct 
as  to  render  it  doubtful  wliether  the  patient  sufl'ers  from  ascites  ov 
from  encysted  dropsy.  The  grounds  of  diagnosis,  and  which  in 
the  great  majority  of  cases  suffice  for  the  ready  distinction  between 
the  two  conditions,  are  the  following:  Ascites  is  generally  pre- 
ceded and  accompanied  by  considerable  disorder  of  the  general 
health,  usually  of  a  febrile  character;  it  is  comparatively  acute  in 
its  develo[)ment,  is  often  associated  with  anasarca,  almost  always 
with  very  scanty  secretion  of  urine;  in  many  cases  with  albuminuria, 
in  all  of  which  respects  it  diflers  essentially  from  ovarian  dropsy. 
Examination,  too,  yields  a  difterent  result  in  the  two  diseases.  The 
enlargement  of  the  abdomen  is  symmetrical  in  ascites;  while  in 
ovarian  dropsy  one  side  is  often  manifestly  more  prominent  than 
the  other.     In  ascites  the  abdomen  is  flattened,  spreading  out  at 


430  DiA||i^ 


OSIS 


either  side:  in  ovarian  dropsy  the  tumor  is  distinctly  most  promi- 
nent towards  the  mesial  line,  somewhat  as  is  the  case  in  pregnancy, 
while,  when  the  size  of  the  tumor  is  very  considerable,  it  spreads 
out  the  floating  ribs,  and  imparts  a  conical  form  to  the  thorax, 
which  is  not  produced  by  mere  ascites.  Percussion  over  the  front 
of  the  abdomen  almost  invariably  yields  a  dull  sound  in  ovarian 
dropsy,  for  it  scarcely  ever  happens  that  any  coils  of  intestine  are 
interposed  between  the  enlarged  ovary  and  the  abdominal  w'alls. 
In  ascites,  on  the  other  hand,  the  intestines  float  as  near  the  sur- 
face as  the  mesentery  to  which  they  are  tethered  will  permit;  and 
hence  percussion  over  the  front  of  the  abdomen  gives  out  a  clear 
sound;  or  should  there  at  first  be  dulness,  owdng  to  the  presence 
of  a  large  quantity  of  fluid,  it  suftices  to  press  a  little  firmly,  so  as 
to  displace  some  of  the  fluid,  and  bring  the  hand  nearer  to  the 
intestines  in  order  to  elicit  a  clear  sound,  or  at  least  a  semi-reso- 
nance, which  is  equally  characteristic.  As  the  patient  wnth  ascites 
lies  upon  her  back,  percussion  yields  a  dull  sound  in  either  lumbar 
region;  while  if  she  turns  upon  her  side,  resonance  is  at  once  per- 
ceived on  that  side  which  is  uppermost.  When  to  this  is  added 
that  ascites  seldom  exists  long  without  being  attended  by  some 
obstruction  of  the  abdominal  circulation,  and  by  an  attempt  at 
compensating  for  it  by  enlargement  of  the  superficial  abdominal 
veins;  and  lastly,  that  some  trace  of  the  outline  of  the  tumor  can 
usually,  with  care,  be  made  out  in  cases  of  ovarian  dropsy,  I  have 
enumerated  all  the  customary  signs  of  each  attection. 

Various  causes,  however,  complicate  a  question  which  seems  so 
simple,  and  one  might  almost  console  one's  self  for  one's  own  errors 
of  diagnosis  in  these  cases  by  finding  how^  many  and  how  eminent 
are  the  men  who  have  confessed  to  the  like  mistakes.  Cruveilhier^ 
mentions  seeing  a  lady  in  whom  an  encysted  dropsy  of  the  ovary 
had  been  taken  by  two  very  experienced  practitioners  for  ascites, 
and  it  was  not  until  after  a  second  very  careful  examination  of  the 
patient  that  they  were  convinced  of  the  error  of  their  opinion,  and 
of  the  correctness  of  the  view  adopted  by  Cruveilhier;  while  Boinet 
confesses^  that  he  on  one  occasion  injected  the  peritoneum  with  a 
solution  of  iodine,  under  the  impression  that  the  case  was  one  of 
ovarian  dropsy.  ^lost  of  the  mistakes  which  are  conmiitted  are  of 
this  latter  kind,  and  many  circumstances  contribute  to  render  this 
the  form  of  error  to  which  practitioners  are  most  liable.  Now  and 
then,  indeed,  we  meet  with  exceptions  to  the  development  of  ovarian 
dropsy  during  a  comparatively  good  state  of  the  general  health.  A 
patient,  aged  forty-two,  was  admitted  into  St.  Bartholomew's  Hos- 
pital, in  whom  the  formation  of  an  ovarian  tumor  exactly  coincided 
with  an  attack  of  general  dropsy  and  albuminuria  produced  by  ex- 
posure to  cold.  Greatly  impaired  health,  and  a  scanty  secretion 
of  urine,  wdiich  was  loaded  with  albumen,  still  persisted  at  the 
time  of  the  woman  coming  under  my  notice  five  months  after- 

^  Anatomie  Pathologique,  vol.  iii,  p.  400. 
2  lodothh-apie,  etc.,  8vo.,  Paris,  1855,  p.  206. 


FROM    ASCITES.  431 

wards ;  but  the  characters  of  the  tumor  were  fortunately  too  well 
marked  for  its  nature  to  be  overlooked. 

The  opposite  error  is  especially  likely  to  be  committed  in  those 
cases  in  which  ascites,  depending  on  some  obstacle  to  the  portal 
circulation,  such  for  instance  as  occurs  in  cirrhosis  of  the  liver, 
comes  on  without  any  active  symptoms  or  any  important  disturb- 
ance of  the  general  health.  Such  a  case  was  that  of  a  woman, 
aged  thirty-four,  who  was  received  into  St.  Bartholomew's  Hos- 
pital, sufiering  from  urgent  dyspnoea,  owing  to  the  enormous  dis- 
tension of  the  abdomen,  which  measured  forty-four  and  three- 
quarter  inches  in  circumference.  Tapping  was  at  once  performed, 
and  thirty-one  pints  of  serum  were  evacuated  with  great  and  im- 
mediate relief  to  her  symptoms.  The  patient  then  stated  that  after 
experiencing  vague  pains  in  her  limbs,  her  abdomen  eighteen 
months  before  began  to  enlarge,  and  as  her  menstruation,  previ- 
ously regular,  had  now  become  sus[)ended,  she  at  first  fancied  her- 
self pregnant.  After  an  interval  of  three  months,  however,  the 
menses  returned,  and  had  subsequently  become  much  more  profuse 
than  formerly.  This  weakened  her;  but  until  her  respiration  began 
to  be  interfered  with  by  the  enormous  enlargement  of  the  abdomen, 
no  grave  symptoms  of  ill-health  had  appeared.  The  skin  was  not 
icteroid,  and  a  day  or  two  after  the  tapping  the  patient  expressed 
herself  as  feeling  quite  comfortable;  her  tongue  was  clean,  her 
bowels  were  regular,  her  appetite  was  good,  and  she  slept  well. 
The  history  of  the  patient,  and  her  general  condition,  might  have 
misled  one  ;  but  the  following  circumstances  abundantly  guarded 
against  error: 

1st.  The  fact  that  no  tumor  or  cyst  had  been  distinguished  after 
the  first  tapping,  and  that  on  the  re-accumulation  of  the  fluid  no 
distinct  limitation  of  the  swelling  in  any  direction  could  be  dis- 
covered. 

2d.  The  existence  of  distinct  resonance  on  percussion,  in  spite 
of  the  enormous  distension  of  the  abdomen,  while  at  the  same 
time  there  was  none  of  that  bulging  outwards  of  the  floating  ribs 
which  a  solid  tumor  of  such  dimensions  would  occasion. 

3d.  The  procident  condition  of  the  uterus,  while  that  organ  is 
commonly  though  not  invariably  drawn  upwards  by  an  ovarian 
tumor. 

4th.  The  enlargement  of  the  superficial  abdominal  veins,  and 
the  presence  of  a  very  obvious  irregular,  nodular  enlargement  of 
the  liver. 

The  signs  that  in  this  instance  kept  from  error  may  be  almost 
entirely  absent;  and  then,  as  in  the  painful  case  which  T  will  next 
relate  for  your  warning,  a  little  oversight,  a  little  want  of  vigilance 
and  care,  may  suffice  to  lead  us  grievously  wrong. 

A  young  girl,  aged  seventeen  and  a  half  years,  was  sent  up  from 
the  country,  alleged  to  be  suffering  from  ovarian  dropsy,  which  her 
appearance  and  history  confirmed.  Her  abdomen  measured  ibrty- 
one  inches;  it  was  generally  dull  on  percussion,  exeej>t  in  both 
lumbar  regions,  where  there  was   semi-resonance  on   the  right 


432  ASCITES    MISTAKEN    FOR 

side  and  a  clear  sound  more  marked  and  more  extended  on  the 
left.  Her  history  was,  that  having  begun  to  menstruate  at 
fifteen,  the  catamenia  continued  regular  for  twelve  months,  when 
they  ceased  in  consequence  of  a  fright  at  a  menstrual  period.  Her 
health,  however,  still  remained  pretty  good,  but  about  five  months 
before  she  came  under  my  notice  the  abdomen  began  to  enlarge, 
and  for  a  month  this  enlargement  had  been  going  on  with  great 
rapidity,  and  her  respiration  had  become  impeded,  while  some 
swelling  of  the  legs  had  taken  place  within  a  week.  There  was 
no  enla'i-gement  of  the  superficial  abdominal  veins  ;  the  generally 
dull  sound  on  percussion,  with  the  resonance  in  the  lumbar  re- 
gions, the  patient's  age,  her  history,  all  tallied  so  exactly  with 
the  opinion  said  to  have  been  expressed  by  her  previous  medical 
attendant,  that  no  doubt  was  for  a  moment  entertained  as  to  her 
disease  being  ovarian  dropsy.  Twenty  pints  of  clear,  yellowish 
serum  were  let  out  with  great  relief,  a  bandage  was  applied  to 
the  abdomen,  and  no  bad  symptoms  followed.  In  eleven  days, 
the  fluid  having  re-collected,  seventeen  pints  were  once  more  let 
out,  and  oX.  of  a  solution  of  iodine  were  thrown  in  through  the 
eanula,  and  so  com[)letely  was  the  nature  of  the  case  taken  for 
granted,  that  this  was  not  preceded,  as  it  ouglit  to  have  been,  by 
a  repetition  of  careful  examination  of  the  abdomen.  The  injec- 
tion caused  some  pain  and  alarming  faintness,  and  until  the  pa- 
tient's death  in  sixteen  and  a  half  hours  great  faintness  was  the 
prevailing  symptom.  There  was  but  little  pain,  no  anxiety  of 
countenance,  no  restlessness,  or  jactitation  ;  and  though  the  pulse 
was  very  feeble,  yet  for  eight  hours  the  heart's  action  was  good 
and  regular,  the  patient  dozed  occasionally,  and  awoke  sensible. 
After  that  time,  however,  more  marked  collapse  came  on,  the  sur- 
face became  cold,  vomiting  occurred  frequently,  and  sinking  thus, 
she  died  with  very  little  sufiering,  and  retaining  her  intellect  un- 
clouded almost  to  the  last. 

Examination  of  the  body  discovered  intense  congestion  of  the 
peritoneum,  a  few  adhesions  between  the  coils  of  intestine  in  the 
upper  part  of  the  abdomen,  and  more  numerous  adhesions  lower 
down,  but  no  effusion  into  the  abdominal  cavity,  nor  any  general 
deposit  of  lymph  on  either  surface  of  the  peritoneum.  The  uterus 
and  its  appendages  were  liealth}-,  there  was  no  tumor  anywhere, 
but  the  liver  was  shrunken  to  half  its  natural  size,  and  in  a  state 
of  very  far  advanced  cirrhosis. 

Both  of  these  cases  are  instructive,  but  the  latter  is  especially 
so.  It  teaches  the  sleepless  watchfulness  which  alone  can  guard 
from  error,  the  importance  of  not  taking  anything  upon  trust, 
nor  of  allowing  our  judgment  to  be  swayed  by  any  previously 
expressed  opinion  as  to  the  nature  of  the  disease,  when  once  a 
patient  comes  under  our  care,  and  we  assume  the  responsibility 
of  her  management.  It  shows  the  need,  too,  of  not  taking  the 
previous  history  upon  any  other  person's  authority,  but  of  cross- 
examining  botli  the  patient  and  her  friends  ourselves.  In  this 
instance  it  was  ascertained  after  the  patient's  death  that  her  sister 


OVARIAN    DROPSY.  433 

had  died  of  disease  of  the  liver,  and  that  the  fright  which  was 
followed  by  suppression  of  the  catainenia,  was  succeeded  also  by 
severe  [)ain  in  the  riglit  hypochondriuni,  and  by  great  sallowncss 
of  the  complexion,  which  subsequently  passed  away.  These  facts 
would  doubtless  have  awakened  attention  to  the  possibility  ol"  the 
fluid  in  tlie  abdomen  being  dependent  on  some  visceral  disease, 
though  the  existence  of  advanced  cirrhosis  of  the  liver  in  so  youno- 
a  person  is  undoubtedly  an  exceptional  occurrence.  The  case 
shows,  moreover,  that  enlargement  of  the  superficial  abdominal 
veins  is  not  a  constant  attendant  on  obstruction  of  the  portal  cir- 
culation, while  it  further  proves  that  resonance  in  the  lumbar 
region  is  not  so  trustworthy  an  evidence  of  encysted  dropsy  as  is 
commonly  supposed.  The  presence  of  a  considerable  amount  of 
flatus  in  the  large  intestine  may  cause  percussion  to  yield  a  clear 
sound,  and  this  is  especially  the  case  on  the  right  side,  where  the 
varying  relations  of  the  csecum  greatly  modi ty  the  result  which 
we  obtain.  Lastly,  we  may  deduce  the  rule,  that  the  distinct  per- 
ception of  the  outline  of  the  tumor  is  a  condition  indis})enHable 
to  any  attempt  at  operation,  and  further,  I  may  add,  that  this 
must  have  been  perceived,  not  simply  on  a  previous  occasion,  but 
also  at  the  very  time  at  which  the  operation,  be  it  what  it  may,  is 
attempted. 

lii  the  cases  which  I  have  related,  no  solid  tumor  existed,  or 
at  least  none  whose  situation  at  all  corresponded  with  that  which 
would  be  occupied  by  the  enlarged  ovary.  Ascites  and  ovarian 
tumor  may,  however,  coincide,  but  the  tendency  of  any  error  in 
diaijnosis  in  such  a  case  will  be  rather  to  overlooking  the  existence 
of  the  tumor,  than  to  misinterpreting  the  ascites.  Sometimes, 
indeed,  the  solid  tumor  is  not  perceptible  until  after  the  removal 
of  the  fluid  by  tapping,  while  in  other  instances  it  is  found,  on 
careful  examination  of  the  abdomen,  that  the  hand,  displacing  the 
superjacent  fluid,  comes  down  here  and  there  upon  a  solid  bod}-, 
whose  exact  dimensions  and  form  it  may  yet  not  be  possible  to 
determine.  It  is  chiefly  as  influencing  our  prognosis  that  the  de- 
tection of  the  solid  tumor  is  of  importance.  Tlie  presence  of  a 
small  quantity  of  fluid  in  the  abdominal  cavity  adds  little  or 
nothing  to  the  gravity  of  the  prognosis  of  ovarian  dropsy.  On 
the  other  hand,  the  })resence  of  a  largo  amount  of  fluid  in  tlie 
peritoneum  associated  with  a  small  solid  tumor  is  always  a  matter 
of  great  moment.  Such  a  tumor  is  seldom  ovarian,  for  ovarian 
tumors,  though  when  large  they  disorder  the  circulation  through 
the  abdominal  vessels,  seldom  so  far  interrupt  it  as  to  jtroduce 
any  considerable  efl'usion.  Solid  tumors  so  situated  as  to  have 
this  effect  are  often  malignant  in  character,  are  very  likely  to 
increase,  and  are  scarcely  at  all  within  reach  of  any  kind  of  inter- 
ference. 

The  distended  bladder  has  been  taken  for  a  dropsy  of  the  ovary, 
but  this  is  an  error  wliich  ought  not  to  be  committed.  The  exactly 
oval  ibrm  of  the  tumor,  its  mesial  situation,  its  tension  as  ascer- 
tained by  external  examination,  the  unchanged  position  of  the 

28 


434  DIAGNOSIS    OF    OVARIAN    DROPSY. 

uterus,  the  absence  of  any  tumor  felt  per  vaginam,  or  if  any  be 
discovered,  its  situation  in  front  of  the  uterus  instead  of  behind 
it,  are  characteristic,  even  if  no  history  of  the  case  were  obtain- 
able. It  is  almost  needless  to  remind  you  that  in  every  instance 
where  the  nature  of  a  tumor  admits  of  doubt,  the  catheter  should 
be  introduced  in  order  to  obviate  the  possibility  of  this  cause  of 
error. 

The  mistake  of  dropsy  of  the  ovary  iov  pregnancy  is  impossible 
so  soon  as  the  case  is  submitted  to  a  thorough  examination,  though 
it  is  far  from  rare  for  idle  whispers  to  be  raised  prejudicial  to  a 
patient's  character  before  she  has  come  under  medical  observation. 
Examination  per  vaginam,  and  the  discovery  of  the  unaltered  state 
of  the  OS  and  cervix  and  lower  segment  of  the  uterus,  as  contrasted 
with  the  closure  of  the  os,  the  soitening  of  the  cervix,  and  the  ex- 
pansion of  the  lower  segment  of  the  womb  which  accompany 
pregnancy,  cannot  but  remove  all  doubt.  In  those  cases,  how- 
ever, in  which  a  mistake  would  be  most  serious  in  its  conse- 
quences, namely,  in  unmarried  women,  we  are  often  precluded 
from  giving  to  any  one  the  slightest  hint  of  our  doubts  or  suspi- 
cions, and  are  consequently  unable  to  suggest  the  expediency  of 
making  a  vaginal  examination.  So  long,  too,  as  an  ovarian  cyst 
docs  not  exceed  the  size  of  the  womb  at  the  fifth  month  of  preg- 
nancy, it  is  by  no  means  unusual  for  it  to  be  elastic  rather  than 
distinctly  fluctuating,  while  tlie  position  of  the  tumor  is  often  so 
neurly  mesial  that  its  situation  does  not  ailord  any  means  of  dis- 
criminating between  it  and  the  gi-avid  uterus.  The  alisence  of 
the  mammary  sympathies,  and  also  of  any  sound  like  the  uterine 
souille,  can  both  in  general  be  ascertained,  and  deserve  great 
reliance,  as  strong  negative  evidence  against  the  existence  of 
pregnancy. 

There  are  still  some  rare  conclitio11s\^voi\\\(i\\vQ.  of  enlargement  of 
the  abdomen  which  may  be  mistaken  for  ovarian  tumors.  Such, 
for  instance,  are  those  large  accumulations  of  fluid  which  have 
been  found  in  the  substance  of  fibrous  growths  of  the  uterus,'  and 
such  the  almost  equally  uncommon  cases  of  encysted  drojisy  of  the 
abdcmien,  where  the  fluid  collects  in  the  sub-peritoneal  cellular 
tissue,  or  between  the  layers  of  the  omentum.'*  One  instance  of 
this  latter  occui-rence  has  come  under  my  own  observation,  in 
which  between  four  and  five  quarts  of  a  dark  fluid  were  found 
collected  between  the  folds  of  the  omentum,  and  during  the  pa- 
tient's lifetime  frequent  discharges  of  a  similar  fluid  had  taken 
place  from  the  umbilicus.  The  dropsy  had  during  the  life  of  the 
patient  been  supposed  to  be  ovarian  ;  but  though  malignant  disease 

1  See  a  reference  to  these  cases  in  a  note  at  p.  220. 

"^  On  the  subject  of  cj'sts  of  the  abdominal  cavity  see  Abeille,  T)-aiU  des  Hydrop- 
sies et  des  Kysies,  8vo.,  Paris,  1852,  pp.  519-587;  Copland's  i)(c/;onari/,  article 
Dropsy,  and  the  references  at  p.  660;  S.  Lee  on  Tumors  of  the  Uterus,  p.  123; 
the  cases  of  Sir  B.  Brodie,  Med.  Gazette,  vol.  i,  p.  334 ;  Dr.  Thomson,  ibid.,  p.  468 ; 
Cruvcilhier,  Traite  d'Anatomie  Pathol.,  vol.  iii,  p.  518;  and  the  papers  of  Mr.  C. 
Hawkins,  Med.  Chir.  Trans.,  vol.  xviii,  p.  175;  and  M.  Chantourclle,  Archives  de 
Med..,  1831,  vol.  xxvii,  p.  218. 


FLOATING    ABDOMINAL    TUMORS.  435 

of  Loth  ovaries  was  discovered,  yet  neither  of  them  contained  fluid 
at  all  similar  in  character  to  that  which  was  found  in  the  omentum  ; 
nor,  indeed,  could  either  be  detected  till  after  the  fluid  in  the 
omental  cyst  had  been  let  out.  I  am  aware  of  no  means  by  wliich 
such  cases  are  to  be  discriminated  from  ovarian  dropsy;  as  far  as 
I  know,  their  nature  has  scarcely  ever  been  suspected  during  the 
lifetime  of  the  patient. 

The  only  conditions  in  which  large  tumors  of  the  spleen  or  liver 
are  likelj'  to  be  taken  for  growtlis  of  the  ovary,  are  when  they  are 
of  very  long  standing,  have  acqnired  a  very  large  size,  and  have 
occurred  in  persons  who  are  either  incapacitated  by  illness  Irom 
telling  their  own  history,  or  wlio  have  been  so  unoljservant  as  not 
to  notice  the  beginning,  and  scarcely  to  attend  to  the  progress  of 
their  disease.  Still,  even  in  these  circumstances  the  prominence 
of  the  tumor  at  the  ui)per  part  of  the  al)domen,the  dulness  in  the 
h3'pochondriac  region,  and  the  fact  that  at  some  jxirt,  if  not  at  all, 
the  lower  Qi\g:Q  of  the  growth  can  be  detected,  will  keep  the  mod- 
erately careful  observer  fnmi  error. 

And  here,  I  think,  we  may  take  leave  of  the  diagnosis  of  ova- 
rian tumor.^     That  fasces  in  the  large  intestine  have  been  taken 

1  I  know  no  place  more  fitting  than  the  present  for  a  brief  reference  to  those 
foaling  nhdom'mal  iumorfi  which  all  practitioners  have  occasionally  met  with,  though 
much  difference  of  opinion  has  prevailed  with  reference  to  their  real  nature. 

All  of  these  tumors  bear  a  very  close  resemhlance  to  each  other,  both  in  size, 
shape,  and  situation.  Thcj'  are  oval  in  form,  usually  about  the  size  of  a  turkey's 
egg,  and  are  generally  situated  in  the  hy))ochondriac  or  lateral  region,  their  lower 
margin  seldom  descending  below  the  level  of  the  iliac  crest.  In  most  instances 
one  tumor  only  is  present,  but  sometimes  there  are  two  in  opposite  sides,  and  for 
the  most  part  symmetrical  in  all  respects.  They  generally  admit  of  displacement 
inwards  towards  the  mesial  line  much  more  readily  than  outwards,  and  upwards 
to  a  far  greater  extent  than  downwards,  so  that  they  can  sometimes  be  pushed  up 
out  of  reach  under  the  floating  ribs,  but  seldom  downwards  into  the  iliac  region, 
and  never  into  the  pelvic  cavity.  They  are  firm,  though  not  without  a  certain 
degree  of  elasticity  ;  their  surface  is  smooth  and  regular;  no  sound  can  be  detected 
in  them  by  means  of  the  stethoscope,  and  they  yield  a  dull  sound  on  percussion, 
modified  only  by  the  presence  of  a  coil  of  intestine  distended  with  air  behind 
them,  when  they  may  yield  a  sort  of  semi-resonance.  Pressure  on  them  is  painful, 
but  the  pain,  which  is  of  a  peculiar,  sickening  character,  usually  passes  oti"  when 
they  are  no  longer  handled.  Sometimes,  however,  they  arc  the  seat  of  a  constant 
■wearing  pain,  which  comes  on  causelessly,  and  continuing  for  hours,  days,  or 
weeks,  subsides  equally  without  occasion,  though  it  may  be  said,  as  a  general  rule, 
to  be  aggravated  by  exertion  and  mitigated  by  rest.  They  have  either  been  acci- 
dentally found  out  on  examination  of  the  abdomen  for  some  other  purpose,  or  the 
pain  experienced  in  them  has  led  to  the  discovery  of  their  jiresence  by  the  [latient. 
Their  rate  of  increase  must  be  slow,  for  though  jiatients  atfected  with  them  have 
for  years  been  under  my  occasional  observation,  1  have  never  ascertained  that 
their  size  has  und(^rgone  any  modification.  I  know  of  one  instance,  too,  in  which 
a  tumor  of  this  descrij)tion  had  existed  for  more  than  twenty  years  in  a  lady  of 
sixty,  unchanged  in  shape,  size,  or  situation.  This  lady  had  been  seen  by  th<>  late 
Dr.  Warren,  by  Sir  Astley  Cooper,  and  Sir  Benjamin  IJrodie,  and  it  may  illustrate 
the  obscurity  which  jirevails  with  reference  to  their  nature  if  I  mention  that 
each  of  these  eminent  men  gave  a  ditlerent  opinion  with  reference  to  it,  one  of 
them  regarding  it  as  connected  with  the  mesentery,  another  as  a  floating  kidney, 
and  a  third  believed  it  to  be  ovarian. 

I  have  a  record  of  thirteen  cases,  of  which  the  chief  particulars  are  rejiresented 
below  in  a  tabular  form  : 


436 


FLOATIXG    ABDOMINAL    TUMORS, 


for  them  ;  that  fat  and  flatus  have  raised  a  suspicion  of  their  pres- 
that  the  abdomen  even  has  been  opened  to  remove  a  tumor 


enee 


Age. 

Tears  married. 

Seat  of  Tumor. 

Period  it  had  existed. 

Symptoms. 

r    Accidentally  dis-    "J 

26 

2 

Right  Hypochondrium. 

J  covered  when  under  I 
j         treatment  for        [ 
(.    another  ailment.    J 

None. 

27 

4 

.    «                   " 

One  year. 

Pain  and  dyspepsia. 

29 

H 

Left  Hypochondrium. 

" 

J  I'ain.  which  came  ) 
(  on  after  e.xertion.  J 

30 

6,  sterile. 

Right  Hypochondrium. 

Eighteen  months. 

Pain  and  dyspepsia. 

35 

Married. 

Both  hypochondria. 

f    Left,  nine  montlia.    > 
I  Right,  three  weeks.  J 

Pain. 

38 

14 

Right  Hypochondrium. 

One  year. 

" 

47 

Married. 

Left  Iliac. 

Seven  years. 

Pain,  occasional. 

60 

/Twice  married,) 
1   now  a  widow,   j' 

Right  Iliac. 

Twenty  years. 

Slight  occasional  pain. 

38 

17 

Right  Hypochondrium. 

Six  months. 

Occasional  pain. 

30 

5 

" 

Three  years:  and  a  half. 
r    Two  years  follow-    "| 

Dull  pain. 

45 

2,  widow. 

»                   « 

J          ing  violent          ( 

Slight  pain  in  right 

j        concussion  on        f 
(            raiUay.            J 

leg. 

40 

20 

11                   « 

■  Thirteen  years  after  ) 
birth  of  a  child.       i 

Dull  pain. 

35 

9 

»                   « 

Accidentally  dis-     \ 
\             covered.             J 

None. 

In  10  cases,  then,  the  tumor  was  seated  on  the  right  side,  in  2  on  the  left,  and 
in  1  on  both  sides,  its  position  having  in  11  out  of  the  13  been  distinctly  in  the 
hypochondrium,  twice  only  in  the  upper  part  of  the  iliac  region,  and  in  those  two 
instances  allowing  of  displacement  upwards,  but  not  at  all  in  a  downward  direc- 
tion. The  connection  of  dy?pi'ptic  sytnptoms  with  the  tuniur  in  the  right  hypo- 
chondrium on  two  occasions  may  suggest  the  probability  of  its  being  sometimes 
formed  by  the  scirrhous  pylorus,  an  hypothesis  which,  in  the  case  of  a  patient 
under  the  care  of  Dr.  Burrows,  was  confirmed  by  post-mortem  examination. 

Some  movable  tumors  ma}-  pos.-ibly  be  connected  with  the  mesentery,  and  some 
may  admit  of  the  explanatit)n  which  1  have  been  informed  that  the  late  Dr.  Aber- 
crombie,  of  Edinburgh,  proposed.  He  thought  that  a  sort  of  spasmodic  constriction 
of  some  of  the  fibres  of  the  colon  inclosed  a  small  collection  of  flatus,  suflicient  to 
form  a  swelling  distinctly  perceptible  by  the  hand  of  the  physician,  but  di.<tin- 
guishable  by  its  resonance  on  peroussiim  from  all  solid  tumors.  1  cannot  say, 
however,  that  I  have  met  with  any  condition  clearly  answering  to  this  description, 
and  have  no  doubt  but  that  movable  abdominal  tumors  presenting  the  characters 
above  described,  are  almost,  or  quite  invariably,  produced  by  disjilaeement  of  the 
kidney.  On  this  hypothesis,  too,  one  can  understand  the  occasional  sudden  ap- 
pearance of  the  swelling  after  a  violent  exertion  or  strain,  as  in  the  case  of  one  of 
my  patients,  in  whom  it  followed  concussion  in  a  railway  carriage,  or  of  a  gentle- 
man in  whom  it  was  produced  by  a  fall  from  horseback.  M.  Cruveilhier*  has 
noticed  these  swellings,  and  has  observed  that  it  is  almost  always  the  right  kidney 
which  is  thus  displaced,  and  that  the  accident,  while  very  rare  in  the  male  subject, 
is  far  from  being  uncommon  in  the  female.  He  attributes  it  to  the  pressure  of 
tightl}'  laced  stays  upon  the  liver.  "The  kidney,"  sa^s  he,  "is  then  compressed 
between  the  liver,  which  is  in  front,  the  lower  ribs,  and  the  vertebral  column, 
which  are  behind,  and  is  squeeezed,  as  it  were,  out  of  the  sort  of  bed  in  whicli  it 
lies  without  being  adherent  to  it,  just  as  a  plum-stone  would  slip  from  between  the 
fingers." 

I  do  not  know  that  any  further  light  has  been  thrown  on  this  accident,  or  on  its 
mode  of  production,  but  a  comparison  of  the  numerous  cases  now  on  record  sub- 
stantiates the  correctness  of  Cruveilhier's  opinion.  In  the  Archives cle  iJedecuie  i't>T 
1859,  vol.  il,  pp.  158  and  301,  M.  Fritz  has  collected  from  various  sources  35  cases 
of  floating  kidney.  Of  these  5  only  occurred  in  the  male,  30  in  the  female.  In 
19  cases  the  right  kidney  was  movable,  in  4  the  left;  and  while  in  7  both  organs 
were  somewhat  misplaced,  the  mobility  of  the  right  kidney  was  in  5  of  these  in- 
stances much  greater  than  that  of  the  left. 


'  Ariatomie  Pathologique  Generale,  vol.  ii,  p.  723. 


OVARIAN    TUMORS    AND     DROPSY.  437 

which  was  found  to  have  no  existence,  proves  only  how  large  is 
the  possibility  of  error,  how  vigilant  must  be  our  care  if  we  will 
avoid  a  danger  which  the  wisest  have  not  always  been  so  fortu- 
nate as  to  escape. 


LECTURE    XXVIII. 

OVAKIAN   TUMORS  AND   DROPSY. 

Treatment;  difficulty  of  estimating  its  results.  Duration  of  life  in  ovarian 
dropsy.  Cases  divisible  into  three  classes:  some  must  be  let  alone,  some  may 
be,  some  require  interference. 

Prophylactic  measures,  and  medicinal  agents. 

Operative  proceedings.  Tapping,  when  absolutely  necessary.  Opinions  as  to 
danger  of  its  performance,  statistics  of  the  subject,  bad  re.sults  possibly  over- 
estimated, circumstances  in  which  early  tapping  may  be  admissible.  Mode  of 
performing  the  operation  ;  danger  of  exhaustion  and  of  cyst  inflammation ; 
their  symptoms  and  treatment. 

• 

There  is  some  fallacy  as  well  as  much  truth  in  almost  all  pop- 
ular sayings.  Even  the  adage  that  a  "doubtful  remedy  is  better 
than  none,"  is  not  of  universal  application,  for  doubtful  remedies 
are  often  dangerous,  and  if  they  fail  to  cure  they  frequently  aggra- 
vate the  disease.  The  danger  of  the  disease  itself  is  an  element 
never  to  be  lost  sight  of  in  our  estimate  of  the  expediency  of 
interfering  with  its  progress ;  and  if  the  present  suffering  it 
occasions  is  but  small,  if  its  advance  is  likely  to  be  slow,  if  it  may- 
be interrupted  by  occasional  pauses,  we  should  hesitate  to  advise 
any  proceeding  by  which,  though  perfect  cure  may  possibly  be 
wrought,  yet,  on  the  other  hand,  life  may  be  cut  short  suddenly. 
The  chances  of  complete  recovery  will  b}-  few  persons  be  felt  to 
overbalance  the  risk  of  immediate  death,  and  I  do  not  think  it 
becomes  us  to  throw  the  weight  of  our  influence  into  the  scale. 

Considerations  of  this  kind  are  nowhere  more  in  place  than  in 
an  inquiry  into  the  treatment  of  ovarian  tumors  and  dropsy — a  class 
of  diseases  which  indeed  tend  progressively  from  bad  to  worse, 
which  often  bring  with  them  much  suffering,  Init  in  which,  never- 
theless, the  sufi:ering  is  not  invariable,  nor  the  downward  tendency 
constantly  progressive,  so  that  we  cannot  limit  their  jiossible 
duration,  or,  from  the  date  of  their  commencement,  calculate  with 
any  approach  to  certainty  the  time  which  will  elapse  before  they 
reach  their  close. 

The  reasons  for  this  uncertainty  are  so  obvious  as  scarcely  to 
need  that  I  should  insist  upon  them  here.  I  may,  however,  re- 
mind you  that  in  many  instances  we  are  unable  to  fix  the  time  at 
which  ovarian  disease  began  ;  so  imperceptible  are  often  its  ad- 
vances, so  few  the  symptoms  that  accom[)any  its  earlier  stages, 
that  not  infrequently  the  growth  has  attained  a  considerable  size 
before  the  attention  of  the  patient,  or  of  her  medical  attendant,  is 


438  UNCERTAINTIES  OF  PROGNOSIS 

drawn  to  its  presence.  Even  after  it  has  been  discovered,  it  is 
often  as  difficult  to  foretell  tlie  future  progress  of  the  disease  as  to 
determine  its  past  duration.  The  cyst  may  long  remain  stationary, 
its  flaccid  walls  announcing  that  absorption  goes  on  more  rapidly 
than  secretion,  or  it  may  possibly  disappear  altogether.  On  the 
other  hand,  just  the  opposite  course  may  be  run ;  the  barren  cyst 
may  become  proliferous,  or  the  compound  cyst  may  suddenly,  and 
apparently  causelessly,  pass  into  a  state  of  active  development,  or 
evidences  of  malignancy  may  manifest  themselves  in  a  growtli  i)re- 
sumed  for  a  long  time  previously  to  be  innocent;  while  to  all 
these  contingencies  must  be  added  those  inseparable  from  the 
various  kinds  of  interference  which  the  mere  palliation  of  the  evil 
in  most  instances  requires.  Advocates  of  the  most  opposite  views 
with  reference  to  the  dangers  attendant  on  ovarian  disease  are  not 
without  ample  support  for  their  opinions:  cases  are  to  be  found  of 
life  continuing  for  years  in  very  tolerable  comfort,  and  even  of  the 
sexual  functions  being  duly  performed,  and  pregnancy  and  labor 
occurring  in  spite  of  it,  the  patient  dying  at  length  of  some  other 
perfectly  different  ailment.  Illustrations  of  just  an  opposite  kind 
are  still  more  numerous,  telling  of  the  rapid  development  of  the 
growth,  of  speedy  impairment  of  the  general  health,  of  death 
occurring  in  one,  two,  or  tliree  years  from  the  commencement  of 
the  evil,  or  of  life  being  cut  short  even  sooner  in  consequence  of 
some  attempt  at  giving  temporary  relief,  which  it  was  not  possible 
any  longer  to  delay. 

The  endeavor  has  been  made,  indeed,  to  arrive  at  more  definite 
results,  and  the  late  Mr.  Safford  Lee'  collected  with  characteristic 
diligence  the  particulars  of  123  cases: 

In  38  of  which  the  disease  lasted  1  year. 

"  25  "  "  2     " 

II  jy  ((  u  3     u 

«  2Q  <(  <(  4     (< 

u     3  u  (I  5     u 

"  14  "  "  5  to  10  years. 

<(     g  II  ((  10  .<  12     " 

K     5  u  a  12  "  16     " 

((     4  (I  u  20  "  25     " 

(I     1  (i  u  50  »« 

123 

ISTow  from  this  table  it  appears  that  90  out  of  123  cases,  or  3 
out  of  4,  or  73.9  per  cent.,  terminated  fatally  within  five  years, 
and  more  than  a  third  of  this  number  within  one  year  from  the 
observed  commencement  of  the  disease.  But,  on  the  other  hand, 
between  the  observed  and  the  real  commencement  of  the  disease, 
there  is,  as  has  already  been  stated,  a  wide  difi^'erence,  and  while 
the  numbers  doubtless  understate  the  duration  of  the  evil  in  many 
cases  where  the  disease  appeared  to  be  most  rapid,  they  prob- 
ably by  no  means  truly  represent  the  degree  to  which  life  was 
often  prolonged  in  spite  of  it.     Even  as  they  stand,  however,  the 

1  On  Tuviors  of  the  Uterus,  p.  177. 


IN    OVARIAN    DROPSY.  439 

numbers  show  that  in  16  out  of  123  cases,  or  nearly  1  in  7,  life 
continued  for  a  period  of  from  ten  to  fifty  years;  and  it  must  not 
be  forgotten,  that  when  a  disease  has  been  long  quiescent,  the 
patient  learns  to  think  but  little  of  it;  she  speaks  of  it  stdl  less; 
even  her  medical  attendant  is  perhaps  scarcely  aware  of  its  ]»res- 
euce;  and  when  she  dies  either  of  that  or  of  some  other  aftectiou, 
it  is  doubtful  whether  he  who  sees  the  end  had  also  seen  the  be- 
ginning of  the  malady.  One  other  point  there  is,  concerning 
which  there  can  be  no  doubt,  and  which  invalidates  all  the  statis- 
tics on  the  subject  wherewith  hitherto  we  have  been  furnished; 
and  that  is,  the  wide  disparity  between  the  results  that  diri'erent 
cases  yield.  One  year  and  fifty  years  cannot  both  truly  represent 
the  time  occupied  by  the  same  disease  in  running  its  course.  We 
can  fix  the  duration  of  uterine  cancer  with  tolerable  accuracy,  and 
find  the  disease,  when  seated  in  the  womb,  to  obey  the  same  laws 
as  govern  it  in  other  parts.  We  know,  too,  that  the  slow-growing 
fibrous  tumors  of  the  uterus  have  in  themselves  no  tendency  to 
destroy  life,  though  in  their  course  some  accident  may  occur  to 
compromise  it,  and  many  others  to  render  it  painful.  The  dis- 
crepancy between  the  results  of  diflerent  cases  of  ovarian  dropsy, 
on  the  other  hand,  plaiuly  shows,  what  indeed  the  study  of  its 
morbid  anatomy  has  taught  us,  that  under  this  name  several  dif- 
ferent diseases  have  been  included,  having  different  tendencies, 
warranting  a  different  prognosis,  and  calling  for  different  modes 
of  treatment. 

In  any  inquiry  into  the  treatment  of  the  disease  these  facts 
must  not  be  lost  sight  of,  but  we  must  consider  it  with  reference 
to  the  special  form  of  the  affection  with  which  in  each  separate 
case  we  have  to  do.  The  question  cannot  be  propounded  as  to 
whether  this  or  that  plan  of  treatment  is  suitable  for  ovarian 
dropsy  ;  but,  given  a  certain  form  of  ovarian  disease,  is  this  or  that 
proceeding  expedient  or  allowable;  or  is  it  wiser  to  do  nothing,  or 
to  palliate;  or  is  the  attempt  to  do  more,  justifiable  ;  and  wlicn  at 
length  the  necessity  for  interference  of  some  kind  becomes  abso- 
lutely unquestionable,  are  the  risks  even  of  palliative  proceedings 
80  considerable  as  to  warrant  a  greater  hazard  being  run  for  the 
chances  of  a  perfect  cure  ? 

All  cases'  of  ovarian  dropsy  and  tumor  may  for  the  purposes  of 
therapeutics  be  considered  as  belonging  to  one  or  other  of  three 
classes,  according  as  they  are,  either 

1st.  Cases  which  mai/  be  let  alone. 

2d.  Cases  which  must  be  let  alone. 

3<1.  Cases  justifying,  or  ahsolutehj  rerjuinng  inferferennp.. 

All  cases  of  ovarian  dropsy,  or  of  tumor  undistinguishable  from 
it,  maj/  be  let  alone  in  which  the  growth  does  not  exceed  the  size 
of  two  fists,  in  which  its  position  does  not  seriously  disturb  the 
functions  of  the  pelvic  viscera,  in  which  it  is  unaccompanied  by 
severe  suffering,  and,  as  far  as  can  be  ascertained,  is  not  in  course 
of  rapid  increase.  Furtlier,  in  proportion  to  tlie  small  size  of  the 
tumor,  to  the  smoothness  of  its  surface,  to  its  elasticity  when 


4^0  TREATMENT  OF  OVARIAN  DROPSY. 

pressed  upon,  and  to  its  mobility,  will  be  the  amount  of  encourage- 
ment which  we  shall  be  able  to  afford  to  the  patient,  since  tliere 
will  be  the  more  reason  for  hoping  either  that  the  tumor  is  one  of 
those  cysts  of  the  Wolffian  bodies,  which  never  exceed  certain  com- 
paratively small  dimensions,  or  that  it  may  possibly  be  a  mere 
dropsy  of  the  Fallopian  tube,  which,  though  not  equally  limited 
in  the  size  to  which  it  attains,  has  in  it  nothing  of  the  serious 
character  that  belongs  to  ovarian  dropsy.  Even  in  cases,  too,  in 
which  neither  of  these  hypotheses  is  correct,  it  may  still  bo  re- 
membered, that  an  ovarian  cyst,  while  small,  is  far  more  likely  to 
remain  stationary  than  when  it  has  attained  a  considerable  size. 
The  mere  size  of  the  tumor,  however,  provided  it  does  not  by  its 
bulk  disturb  the  general  health,  cannot  be  taken  as  an  indication 
for  interference.  The  old  maxim,  "  Quieta  non  movere,"  is  at 
least  as  applicable  in  medicine  as  in  politics,  and  you  will  remem- 
ber the  instance  which  I  mentioned  to  you,'  where  a  tumor  con- 
siderably larger  than  the  adult  head,  remained  for  many  years 
stationary;  and  when  it  did  increase,  was  yet  long  before  the 
operation  of  tapping  became  necessary. 

Still,  when  it  is  said  that  such  tumors  are  to  be  let  alone,  I  do 
not  wish  to  imply  that  no  precautions  should  be  observed,  or  that 
nothing  can  be  done  to  retard  their  growth.  These  precautions, 
however,  are  comparatively  few,  and  abundantly  simple.  They 
may  be  summed  up  as  consisting  in  the  endeavor  to  maintain 
the  general  health,  and  to  prevent  congestion  of  the  pelvic  viscera. 
The  first  indication,  I  conceive,  implies  the  avoidance  of  all  such 
proceedings  as  courses  of  mercury,  of  iodine,  of  iodide  of  potass, 
or  of  liquor  potassse,  agents  of  whose  power  in  retarding  the  de- 
velopment of  ovarian  cysts  there  is  scarcely  any  evidence,  while 
of  their  injurious  influence  on  the  constitution,  when  long  con- 
tinued, there  is  the  most  abundant  proof.  To  carrj'  out  the  second 
object,  we  should  certainly  dissuade  a  person  affected  with  this 
disease  from  contracting  hny  matrimonial  engagement;  though 
between  that  and  the  non-fulfilment  of  an  engagement  already 
formed,  or  the  separation  of  a  married  woman  from  her  husband's 
bed,  there  is  a  wide  difference,  and  moral  considerations  enter 
into  the  question  which  more  than  counterbalance  mere  medical 
rules.  Besides  this,  too,  it  is,  I  think,  very  doubtful  whether  in 
the  m^'sterious  influence  of  the  mind  over  the  body,  disappointed 
aftection,  or  the  removal  of  a  wife  from  her  husband's  bed,  would 
not  act  more  injuriously  even  on  the  sexual  system  itself,  than  the 
physical  causes  wdiich  alone  our  restrictions  can  control.  8exual 
intercourse,  however,  should  be  moderate,  and  inasmuch  as  the 
influence  of  pregnancy  and  labor  is  often,  though  by  no  means 
always  unfavorable,  giving  rise  in  many  cases  to  irritation  of  the 
cj'st,  to  a  more  rapid  increase  of  its  growth,  to  inflammation  of 
its  peritoneal  surface,  and  the  formation  of  adhesions;  or  of  its 
interior,  and  to  consequent  outpouring  of  pus,  it  is  desirable  that 

1  Lecture  xxxvi,  p.  408. 


CASES    TO    LET    ALONE.  441 

intercourse  slionld  not  take  place  at  those  seasons,  just  before  or 
just  after  a  menstrual  period,  when  conception  is  most  likely  to 
occur. 

The  condition  of  the  bowels  must  always  be  most  carefully 
watched,  and  every  attention  must  be  paid  to  insure  the  perfectly 
ref!;ular  performance  of  the  menstrual  function.  If  the  meustrual 
period  is  attended  by  any  febrile  disturbance,  or  by  any  increase 
of  pain  in  the  tumor,  the  patient  must  be  kept  strictly  in  bed,  and 
four  or  six  leeches  must  be  applied  over  the  painful  spot,  and 
repeated  every  second  or  third  day  so  long  as  the  pain  continues; 
a  warm  poultice,  or  fomentations  with  spongiopiline  being  con- 
stantly employed  in  the  intervals.  As  soon  as  the  tumor  has 
risen  completely  into  the  abdomen,  a  well-adapted  bandage  should 
be  worn,  partly  for  the  comfort  which  it  seldom  fails  to  afford  to 
the  patient,  partly  because  a  cyst  fills  far  less  rapidly  when  mod- 
erate compression  is  made  upon  it  than  when  no  counter-pressure 
is  employed  to  resist  the  accumulation  of  the  fluid. 

It  has,  I  know,  been  alleged  that  the  power  of  medicine  over 
this  disease  is  much  more  considerable  than  I  have  represented. 
So  great,  too,  is  the  influence  of  a  name  in  determining  the  con- 
duct of  most  of  us,  that  almost  all  the  remedies  of  known  efticacy 
in  ascites  have  been  assumed  to  be  beneficial  in  ovarian  dropsy. 
There  can  be  no  doubt,  too,  but  that  under  the  influence  of  such 
remedies  very  appreciable  diminution  in  the  size  of  the  abdomen 
has  taken  place — a  diminution,  however,  which  I  believe  to  be 
due  to  the  absorption  of  the  fluid,  which  in  many  cases  of  abdom- 
inal tumor  is  poured  out  into  the  peritoneal  cavity,  and  not  to 
any  modification  of  the  contents  of  the  cyst. 

Some  ovarian  tumors,  it  was  said,  might,  others  must,  be  let 
alone.  The  latter  are  all  those  cases,  for  the  most  part  of  rather 
ra[iid  growth,  whose  irregular  nodulated  surface,  and  whose  solid 
non-fluctuating  mass  suggests  the  idea  that  they  are  not  mere 
compound  cysts,  but  productions  of  a  malignant  character.  In 
most  of  such  cases,  too,  we  find  in  the  patient's  history  other 
grounds  still  more  cogent  than  the  anatomical  peculiarities  of  the 
tumor  for  avoiding  all  interference.  Such  are  the  facts  that  the 
general  health  has  failed  simultaneously  with  the  develoi»ment  of 
the  tumor,  and  that  loss  of  flesh  and  loss  of  strength  have  been 
early  attendants  on  its  progress,  and  have  not  first  appeared  when 
the  diflerent  functions  of  the  body  had  been  disordered  by  ita 
bulk,  or  when  nutrition  might  be  supposed  to  be  impaired  by  the 
tax  levied  on  the  system  'iov  the  supply  of  the  mass.  Unhapi>ily, 
the  cases  which  seem  most  to  call  for  help  are  those  in  which  it 
is  least  possible  to  aftbrd  it,  while  it  is  in  precisely  those  which 
may  most  safely  be  let  alone  that  interference  has  the  best  chance 
of  success. 

Between  these  two  classes,  however,  there  is  a  third  in  which 
present  relief  is  called  for,  and  in  which  it  is  in  our  power  to  aflbrd 
it.  It  is  just  in  these  cases  that  we  encounter  the  inquiry  as  to  the 
comi)arative  risks  and  comparative  merits  of  diflerent  proceedings, 


442  TREATMENT    OF    OVARIAN    DROPSY. 

whether  it  is  much  more  hazardous  to  attempt  to  remove  the  evil 
than  to  palliate  it  for  a  time  with  the  almost  absolute  certainty 
tliat  again  and  again  it  will  return,  and  that  on  each  occasion  our 
power  to  palliate  it  will  diminish?  '^or  is  the  question  altogether 
confined  to  these  eases.  The  uncertain  tenure  of  health  and  life, 
even  in  instances  where  the  evil  seems  quiescent,  suggests  the 
importance  of  discovering  some  proceeding  which  entails  no 
greater  hazard  than  we  can  conscientiously  advise  our  patient  to 
encounter  for  a  reasonable  prospect  of  ol)taining  so  great  a  good, 
and  of  freeing  herself  from  danger  ever  impending,  like  the  fabled 
sword  which  hung  over  the  guest  at  the  banquet. 

Very  numerous,  indeed,  are  the  solutions  which  have  been  pro- 
posed to  these  inquiries.  It  is  our  duty  carefully  to  examine  their 
merit,  and  carefully  to  scrutinize  the  different  surgical  proceedings 
that  have  been  recommended  for  the  relief  or  the  cure  of  ovarian 
dropsy. 

The  first  of  these  proceedings  which  we  must  notice,  the  simplest, 
the  least  hazardous,  and  at  the  same  time  the  most  generally  ajtpli- 
cable,  is  the  operation  of  tapping.  Simple  as  it  is,  however,  opinion 
is  nmch  divided 'with  reference  to  the  circumstances  that  warrant 
its  performance;  for  while  some  practitioners  look  upon  it  as  too 
dangerous  to  be  justified  by  anything  short  of  most  absolute 
necessity,  others  consider  it  to  be  attended  by  little  risk,  and  to 
be  a  palliative  all  the  more  valuable  since  it  is  sometimes  followed 
by  a  perfect  cure. 

Two  questions  then  come  before  us.  The  first  of  these  concerns 
the  circumstances  which  by  unanimous  consent  justify  the  per- 
formance of  tapping  as  a  palliative  in  cases  of  ovarian  dropsy. 
The  second  refers  to  the  amount  of  hazard  attendant  on  the  opera- 
tion, and  the  consequent  expediency  or  inexpediency  of  having 
recourse  to  it  when  not  actually  compelled  by  the  urgency  of  the 
patient's  symptoms. 

The  operation  is  absolutely  indicated  in  all  cases  where  the  bulk 
of  the  tumor  is  so  considerable  as  seriously  to  interfere  with  the 
patient's  health,  or  to  occasion  her  very  severe  suftering;  and  this, 
be  the  supposed  nature  of  the  tumor  what  it  may.  In  proportion 
as  the  contents  of  the  tumor  are  fluid  will  the  relief  gained  by 
the  operation  be  considerable ;  but  even  though  its  great  bulk 
should  be  solid,  still  the  diminution  obtained  by  letting  out  even 
some  ounces  may  aftbrd  considerable  temporary  relief  to  the  pa- 
tient, and  will  fully  justify  the  experiment. 

The  state  of  things  which  calls  thus  imperatively  for  interference 
varies  considerably  in  difterent  patients,  and  is  far  from  being  ab- 
solutely connected  either  Avith  a  certain  duration  of  the  disease,  or 
with  a  certain  size  of  the  abdomen.  A  slowly-increasing  growth 
will  often  attain  to  a  very  large  size  indeed  before  it  causes  serious 
disorder,  and  a  tumor  whose  contents  are  entirely  fluid  com- 
monly produces  less  distress  than  one  even  of  smaller  size,  into  the 
composition  of  which  solid  matter  enters  in  large  proportion.  One 
reason  of  this  probably  is,  that  solid  tumors  more  frequently  press 


INDICATIONS    FOR    TAPPING.  443 

upon  the  abdominal  vessels,  interfering  with  the  circulation  thro'ngh 
them,  producing  effusion  into  the  peritoneal  cavity,  and  distuibiug 
the  ki(hieys  in  the  ])erformance  of  their  function.  Ortliopiicea, 
habitual  shortness  of  breath,  even  when  .no  exertion  is  made,  com- 
plete loss  of  appetite,  or  sickness,  owing  in  part  to  the  stomach 
being  mechanically  prevented  from  retaining  food,  pain  referred 
to  the  liver,  and  obstinate  constipation,  with  frequent  colicky  pains 
independent  of  the  action  of  the  bowels,  a  very  scanty  secretion 
of  urine,  and  a  very  feeble  and  thready  pulse,  with,  jieihaps, 
irregularity  of  the  lieart's  action, — such  are  tlie  symptoms  which, 
when  they  begin  to  occur,  indicate  the  immediate  necessity  for 
tapping.  Mere  unwioldiness  in  moving  about,  or  discomfort  from 
the  tension  of  the  abdominal  integuments,  though  perhaps  very 
painful  to  bear,  cannot  be  regarded  as  absolute  indications  for 
the  operation;  and  time  not  infrequently  habituates  a  person  to  a 
state  of  things  which  at  first  seemed  almost  intolerai)le.  Even 
the  circumstance  that  a  tumor  is  steadily  on  the  increase  cannot 
be  taken  as  necessarily  calling  for  the  operation,  since  ovarian 
cysts,  though  large,  sometimes  come  to  a  stand-still,  and  to  decide 
in  favor  of  interference  when  it  is  possible  for  a  short  time  longer 
to  dela}^  it,  implies  that  we  have  answered  to  our  own  satisfaction 
the  second  question  as  to  the  amount  of  risk  attendant  upon  simple 
tapping. 

In  the  cases  hitherto  referred  to,  the  dangers  of  the  operation 
scarcely  enter  as  an  element  into  our  consideration,  but  tapping 
takes  its  place  in  the  same  Category  wnth  various  other  operations 
of  necessity,  such  as  amputation  performed  in  consequence  of  in- 
juries, which,  liow  serious  soever  might  be  the  risk  attendant  on 
them,  would  still  be  most  legitimate,  because  the  only  resources 
at  our  command. 

It  would,  however,  be  unreasonable  to  expect  that  an  operation 
performed  in  these  circumstances  shonld  be  free  from  danger,  and 
this  danger  arises  chiefly  from  two  sources.  Great  as  the  relief 
often  is  to  the  patient,  a  certain  amount  of  shock  follows  the 
evacuation  of  a  large  quantity  of  fluid,  and  patients  previously 
much  exhausted  sometimes  sink  in  two  or  three  days  after  tap- 
ping. In  spite  of  the  warning  given  to  the  patient  tluit  tapping 
will  in  this  way  probably  shorten  her  days,  the  choice  is  not  in- 
frequently made  to  submit  to  a  proceeding  which  brings  at  least 
present  ease;  nor  have  I  thought  myself  failing  in  ni}'  duty  if, 
when  our  art  was  almost  powerless,  I  tried  to  secure  the  last  boon 
our  patients  ask  of  us, — a  euthanasia.  The  other  danger  is  one 
of  inflammation  of  the  cyst-walls,  issuing  in  the  eftusion  of  lymph 
and  ])ns  into  its  interior,  and  not  infrequently  associated  with  ]>eri- 
tonitis  which  often  proves  fatal  in  the  course  of  two  or  three  days. 
This  latter  occurrence,  too,  seems  to  be  of  greater  fro piency  alter 
first  tappings  than  in  those  cases  where  the  operation  has  been  fre- 
quently performed,  while  death  from  mere  collapse  is,  as  might  be 
supposed,  more  likely  to  occur  where  recourse  has  often  been  had 
to  tapping.     Besides  these  two  risks,  which  not  unnaturally  have 


444  RISKS    ATTENDANT 

led  practitioners  to  shrink  from  this  operation,  another  objection 
has  been  nrged  to  it  on  the  ground  of  the  increased  rapidity  with 
which,  after  each  time  of  its  performance,  the  fluid  reacciinmhites 
within  the  cyst.  Expressed  in  various  ways,  the  opinion  is  ahiiost 
unanimous  that  tapping  is  but  the  beginning  of  the  end,  and  pa- 
tients are  commonly  advised,  even  at  the  expense  of  great  incon- 
venience and  discomfort,  to  put  up  \\\ih  the  present  ill,  and  not 
to  purchase  prematurely  a  brief  respite  from  suffering  at  so  high 
a  price. 

The  result  of  the  general  impression  as  to  the  danger  of  tapping 
has  been  not  only  to  postpone  its  performance  in  all  cases  to  as 
late  a  period  as  possible,  but  also  to  lead  to  the  endeavor  to  devise 
some  other  proceedings,  which,  if  not  in  themselves  less  hazardous, 
should  at  least  afford  the  chances  of  a  greater  good,  and  otter,  by 
the  high  prize  which  they  hold  out  to  the  fortunate  few,  some 
amends  for  the  hazards  that  all  must  run,  and  in  the  encounter 
with  wdiich  many,  perhaps  most,  must  fail.  Such  endeavors  are 
but  the  expression  of  a  feeling  deeply  rooted  in  the  breasts  of  all, 
and  I  see  nothing  to  reprobate  either  in  the  surgeon  who  advises, 
or  in  the  patient  who  encounters  some  great  present  risk,  when 
in  the  one  scale  is  placed  the  expectation  of  perfect  health, — 
death,  indeed,  in  the  other;  but  still  a  death  which  does  but  an- 
ticipate, by  a  few  months,  the  certain  issue  of  her  present  sufter- 
ing  existence. 

To  judge  at  all  fairly,  however,  on  such  a  question  we  must  not 
overcharge  either  side  of  the  |>icture ;  and  that  which  it  now  con- 
cerns us  to  determine  is  wliether  the  colors  in  wliich  the  results 
of  ta[)ping  have  been  drawn  are  faithful,  or  whether  they  are  not 
somewhat  darker  than  the  facts  of  the  case  altogether  warrant. 

The  chief,  indeed  almost  the  only  numerical  data  of  which  we 
are  possessed  bearing  on  this  subject,  are  derived  from  a  table  of 
20  cases  compiled  by  Mr.  ^outham,'  of  46  collected  by  the  late 
Mr.  S.  Lee,^and  of  64,  the  results  of  which  are  given  by  Professor 
Kiwisch.'* 

Of  these  130  cases,  22  terminated  fatally  within  a  few  hours  or 
days  after  tapping,  and  25  more  in  the  following  six  months,  or, 
in  other  words,  34.7  per  cent,  of  the  cases  ended  in  the  patient's 
death  in  the  course  of  half  a  year  after  the  performance  of  tap- 
ping.    In  114  of  the  130,  death  is  stated  to  have  taken  place 

In  22  within  a  few  hours,  or  in  less  than  ten  days  after  tapping. 
"  25       "       six  months. 
"22       "       one  year. 
"21       "       two  years. 
"  11       "       three    " 
"  13  after  a  period  exceeding  three,  and  sometimes  amounting 

to  several  years. 

114 


»  Med.  Gazette,  vol.  xxxiii,  p.  237,  Nov.  24,  1843. 

^  Op.  cit.,  p.  176.  ^  Oj).  cit.,  vol.  ii,  p.  115. 


ON    TAPPING.  445 

III  109  of  these  cases  we  are  further  informed  how  often  tlie 
patients  had  been  tapped. 

It  appears  that  46  died  after  the  first  tapping. 
"  10  "  second     " 

"  25  "    from  three  to  six  tappings. 

"  15  "  seven  to  twelve   " 

'*  13  "    more  than  twelve  " 

109 

The  greater  absolute  mortality  attendant  upon  first  tappings  of 
course  does  not  represent  an  equal  amount  of  greater  relative 
danger.  Still,  when  it  appears  that  only  49  of  the  total  180  cases 
were  instances  of  the  first  performance  of  tapping,  and  lurther, 
that  all  the  22  patients  who  died  within  a  period  often  days  from 
the  operation  bad  undergone  it  for  tlie  first  time,  we  are,  I  think, 
compelled  to  admit  that  the  lirst  paracentesis  is  accom})anicd  by 
perils  which  are  greatly  lessened  on  its  repetition.  Ot  38  patients 
of  mine  who  underwent  the  operation  of  paracentesis  abdominis 
on  account  of  ovarian  drops}^  two  died  of  inflammation  of  the  cyst 
within  a  few  days  after  its  first  performance,  one  sank  exhausted 
thirty-six  hours  after  tlie  second  tapping,  and  a  fourth  died  of 
exhaustion  on  the  sixth  day  alter  the  tenth  tapping.  The  others 
all  survived  the  operation,  which  in  one  instance  was  not  repeated 
on  account  of  the  large  amount  of  solid  matter  that  entered  into 
the  composition  of  the  tumor,  and  the  serious  symptoms  which 
had  followed  its  first  performance.  In  one  patient  tlie  fluid  has 
never  re-collected,  and  when  I  last  saw  her,  after  tbe  hqise  of  three 
years,  during  which  time  slie  had  given  birth  to  her  fifth  child, 
all  traces  of  the  tumor  had  disappeared,  and  recovery  miglit  be 
looked  on  as  complete.  In  a  second  the  cyst,  having  refilled, 
spontaneously  subsided,  and  to  the  best  of  my  knowledge  the 
patient  continues  free  from  disease.  •  Three  died  subsequently 
after  attempts  at  the  extirpation  of  the  cyst,  four  sank  under  the 
progress  of  the  disease,  in  the  course  of  which  tapping  was  liad 
recourse  to  more  than  once,  one  died  of  apoplexy,  and  the  remain- 
ing patients  were  still  living  when  I  last  lieard  of  them,  tapping 
in  many  having  been  subsequently  repeated  on  several  occasions, 
and  the  injection  of  a  solution  of  iodine  having  in  eight  instances 
been  resorted  to  with  results  concerning  which  I  shall  have  more 
to  say  hereafter. 

Unfavorable,  however,  as  are  the  conclusions  to  which  we  are 
irresistibly  led  by  facts  such  as  those  which  have  just  been  men- 
tioned with  reference  to  the  ultimate  issue  of  tapping,  it  is  yet  very 
questionable  whether  they  represent  the  whole  of  the  truth  con- 
cerning this  matter.  Some  of  the  data  from  which  the  tables  were 
constructed  were  not  collected  originally  with  the  view  of  illustra- 
ting the  operation  of  taj»ping,  while  the  majority  of  the  others  are 
deduced  from  observations  in  hospitals,  and  must  therefore,  for 
reasons  obvious  to  all,  yield  a  very  high  average  of  unsuccessful 
results.     The  cases  that  seek  admission  to  those  institutions  are 


446  RULES    ATTENDANT     ON    TAPPING. 

almost  always  the  least  hopeful,  geneililly  the  most  far  advanced, 
not  infrequently  those  of  persons  who  have  sought  out  a  place 
where  death  may  come  to  them  with  less  suHeritig  than  if  they 
awaited  it  in  their  own  homes.  If  relieved,  such  patients  quit  the 
hospital,  and  are  often  lost  sight  of;  so  that  while  the  failures  are 
known,  the  instances  are  frequently  undiscovered  in  which  life  has 
been  prolonged  or  rendered  comparatively  comfortable.  i\lmost 
in  proportion  as  experience  concerning  this  operation  is  derived 
from  hospital  practice,  or  from  observation  in  private,  does  the 
estimate  of  its  danger  appear  to  be  increased  or  lessened,  a  cir- 
cumstance which  seems  to  show  that  the  hazards  of  the  operation 
depend  at  least  as  much  on  the  conditions  that  surround  the  pa- 
tient, as  on  anything  inherent  in  the  proceeding  itself.^ 

It  is,  moreover,  a  question  quite  open  to  debate,  whether  the 
period  at  which  the  operation  is  generally  performed  has  not  con- 
tributed largely  to  its  fatal  issue?  The  delay,  commonly  con- 
tinued until  the  different  functions  are  seriously  disordered,  and 
the  patient's  sufferings  from  mere  mechanical  causes  have  become 
urgent,  may  on  the  whole  be  expedient;  but  it  can  scarcely  be 
doubted  that  it  must  lessen  the  prospects  of  recovery  when  at 
length  the  operation  is  resorted  to.  Besides,  the  favorable  results 
which  are  said  to  have  followed  the  early  performance  of  tapping 
in  some  of  those  instances  where  tight  bandaging  was  associated 
with  it,  renders  it  probable  (due  allowance  being  made  for  the  ex- 
aggeration by  which  nuuiy  of  the  published  reports  of  cases  where 
this  proceeding  was  resorted  to  are  vitiated)  that  the  mere  act  of 
tapping  in  certain  selected  cases  of  ovarian  dropsy  is  unattended 
by  any  considerable  hazard. 

The  whole  of  this  subject  needs  a  much  more  searching  inves- 
tigation than  it  hitherto  has  received;  but  in  default  of  this,  I 
will  venture  to  give  my  own  impressions,  and  I  do  so  as  mere  im- 
pressions, which  further  experience  may  modify  or  completely 
change.  My  present  belief,  however,  is  that  the  dangers  of  the 
operation  of  tapping  have  on  the  whole  been  over-estimated;  and 
further,  that  while  in  cases  where  the  amount  of  solid  matter  in 
the  growth  is  considerable,  the  rule  which  prescribes  the  postpone- 
ment of  the  operation  to  the  latest  possible  period  is  a  sound  one, 
it  will  probably  be  more  expedient  in  the  case  of  simple  ovarian 
cysts  to  tap  early,  before  the  growth  has  acquired  a  large  size,  and 

'  In  the  Amei-ican  Journal  of  Medical  Sciences,  vol.  xix,  New  Series,  April,  1850, 
p.  334,  are  some  observations  on  the  mortality  attendant  on  tapping  by  Dr.  W. 
Atlee,  showing  that,  even  tried  by  such  evidence  as  that  adduced  by  Mr.  S  Lee, 
the  tendency  of  the  operation  is,  on  the  whole,  to  prolong  life,  not  to  shorten  it. 
M.  Velpeau,  too,  in  a  discussion  at  the  Academic  de  Medecine  (Journal  Heb<lo7na- 
daire,  Nov.  28,  1856),  demurs  to  the  accuracy  of  the  generally  received  opinion  of 
the  great  mortality  arising  from  simple  tapping.  He  admits  that  in  one  year  he 
lost  four  patients  after  tapping ;  but  these  were  exceptional  cases  of  large  compound 
cysts,  which  it  was  found  possible  to  empty  only  very  partially.  With  these  ex- 
ceptions he  has  performed  the  operation  312  times,  on  about  98  patients,  without 
any  serious  results  either  immediate  or  remote,  and  many  of  the  patients  (an  un- 
fortunately vague  expression,  which  much  detracts  from  the  value  of  his  statement), 
survived  its  first  performance  ten,  fifteen,  or  twenty  years. 


RULES    FOR    THE    PERFORMANCE    OF    TAPPING.  447 

before  the  constitutional  powers  of  the  patient  have  seriously 
suffered.  The  early  tapping,  too,  will  most  likel}-  become  more 
extensively  resorted  to  if  experience  should  confii-m  the  safety  of 
injections  of  iodine  solutions  into  the  cavity  of  the  cyst. 

The  operation  of  tapping;,  as  it  was  generally  practised  until 
within  the  past  few  years,  wlietlier  for  ascites  or  for  ovai'iaii  droi»sy, 
used  to  appear  a  very  formidable  proceeding.  The  patient,  seated 
on  the  edge  of  the  bed  or  of  a  sofa,  was  supported  in  that  position 
by  a  couple  of  assistants,  while  a  bandage  was  placed  around  her 
abdomen,  which  was  tightene-d  in  i)rop()rtion  as  the  fluid  escaped, 
and  was  adjusted  and  firmly  fastened  before  she  was  replaced  in 
her  bed.  In  spite  of  these  jirecautions,  however,  very  distressing 
faintness  was  often  induced  by  the  operation,  and  actual  syncope 
was  not  very  uncommon.  It  had,  indeed,  been  customary  in  some 
exceptional  cases,  as,  for  instance,  when  the  patient  was  very 
feeble,  to  tap  in  the  recumbent  posture;  l)ut  to  the  best  of  my 
knowledge.  Dr.  Simpson'  was  the  first  person  who  publicly  reccun- 
mcnded  the  general  performance  of  the  operation  in  this  posture, 
and  it  is  now  generally  adopted  by  all  surgeons. 

The  selection  of  this  attitude  avoids  all  the  fuss  and  preparation 
which  are  inseparable  from  ta})ping  the  patient  in  a  sitting  pos- 
ture, and  which  are  so  suggestive  of  the  idea  that  some  formidable 
•  operation  is  sibout  to  be  performed.  Nothing  more  is  necessary 
than  to  bring  the  patient  to  the  edge  of  the  bed,  so  as  to  allow  of 
her  abdomen  projecting  somewhat  beyond  it.  The  bladder  should 
then  be  emptied  by  the  catheter  (a  precaution  for  which  the  vol- 
untary efforts  of  the  patient  are  but  a  very  imperfect  substitute), 
and  it  having  been  clearly  ascertained  that  fluctuation  is  distinct, 
and  that  no  great  thickness  of  solid  matter  is  situated  at  the  point 
selected  for  puncture,  the  skin  may  be  divided  for  a  quarter  of  an 
inch  or  less  with  a  lancet,  and  the  trocar  introduced.  It  has  in 
some  rare  instances  happened  that  a  large  venous  trunk  ramifying 
on  the  surface  of  the  cyst  has  been  wounded  by  the  trocar,  and 
that  tlie  hemorrhage  has  had  a  fatal  issue.^  Sucli  an  accident, 
however,  is  scarcely  to  be  guarded  against  by  any  foresight,  while 
the  risk  of  wounding  the  epigastric  artery  is  pretty  certaiidy 
avoided  by  the  selection  of  the  linea  alba  instead  of  the  linea  semi- 
lunaris as  the  situation  of  the  puncture.  If  there  were  obviously 
considerable  thickness  of  solid  matter  in  the  former  situation,  it 
would  no  doubt  be  our  duty  to  puncture  in  the  linea  semiluiuiris, 
or  at  some  other  part  Avhere  there  seemed  to  be  a  less  thiekness  of 
interveniiifj  substance.  It  is,  however,  (luite  as  easv  to  emiitv  the 
cyst  tlirough  a  puncture  made  in  the  former  situation  as  in  the 
latter,  if  the  patient  incline  a  little  more  over  towards  her  face, 
and  its  greater  safety  renders  it  therefore  generally  preferable. 
All  pressure  of  the  abdomen  in  order  to  get  rid  of  the  fluid  as 

•  FA.  Mrd.  Jouninf,  Oct.,  ISK;  nnd  Ohsfctric  Works,  vol.  i,  p.  239. 

*  A  rc'iimrkiible  instanco  of  fatsil  homorrlin^o  fmm  tlio  wound  of  a  vessel  of  tlie 
omentum  which  adiiered  to  a  largcovarian  cyst  is  related  by  Scunzoni,o/).cj7.,  p.  456. 


448  EXHAUSTION    AND 

completely  as  possible  appears  to  me  inexpedient ;  and  I  think  I 
have  seen  inflammation  of  the  cyst  excited  by  such  manipulations 
when  rather  roughly  performed.  The  application  of  a  flannel 
bandage  afterwards,  though  not  in  general  necessary,  is  usually  a 
comfort  to  the  patient;  and  in  cases  where  any  considerable  por- 
tion of  the  growth  is  solid,  can  scarcelj-  be  dispensed  with,  since, 
unless  supported  by  external  pressure,  the  mass  is  apt  to  fall  from 
side  to  side  with  every  movement  of  the  body  in  a  manner  to 
occasion  much  distress. 

I  have  always  been  accustomed  to  keep  my  patient  in  bed  for  a 
day  before  tapping,  and  for  three  or  four  days  afterwards,  and  to 
select  for  the  operation  a  time  as  distant  as  [)0ssible  from  a  men- 
strual period.  These  precautions,  indeed,  may  not  in  every  case 
be  necessary ;  but,  in  spite  of  histories  such  as  that  of  the  patient 
who  every  three  weeks  used  to  come  by  omnibus  a  distance  of 
some  five  or  six  miles  to  Paris,  and,  having  been  tapped,  imme- 
diately returned  by  the  same  conveyance,  I  believe  them  to  be 
always  expedient.  In  every  instance  of  first  tapping,  where  we 
can  have  no  data  to  guide  us  as  to  the  probable  results  of  the 
operation,  it  is  scarcely  possible  to  err  on  the  side  of  caution. 

The  dangers  attendant  on  the  operation  of  tap[)ing  are  tw^olbld  : 
that  of  exhaustion  on  the  one  hand,  of  cyst-inflammation  on  the 
other.  The  previous  state  of  the  patient's  health  has,  as  might, 
be  expected,  much  to  do  Avith  the  former  occurrence,  but  nothing 
seems  to  furnish  a  guarantee  against  the  latter.  It  sometimes 
happens  that  cyst-inflammation  runs  its  course  with  scarcely  any 
symptoms  other  than  thdse  of  exhaustion ;  or,  rather,  I  imagine 
that  in  patients  previously  much  debilitated,  a  diseased  state  of 
the  blood  is  apt  to  supervene,  and  death  takes  place  from  pyfetnia, 
of  which  the  CA^st-inflammation  is  the  consequence,  not  the  cause. 
In  other  instances,  however,  the  sinking  of  the  patient  is  indei^en- 
dent  of  any  recent  morbid  process,  but  the  slight  shock  of  the 
operation  suffices  to  disarrange  the  frail  machiner}^  and  to  bring 
it  to  a  stand-still.  It  is  well  to  bear  this  risk  in  mind  in  all  cases 
where  the  patient  is  very  weak,  and  to  dissuade  from  tapping, 
unless  most  urgently  called  for  by  the  difficulty  of  respiration,  or 
the  inability  to  retain  food  on  the  stomacli,  which  the  mere  me- 
chanical distension  of  the  abdomen  sometimes  produces.  The 
precaution  of  letting  the  fluid  out  very  slowly,  of  lowering  the 
head  and  shoulders  as  it  escapes,  and  of  only  partially  emptying 
the  cyst,  are  the  means  by  wdiich  the  danger  from  exhaustion  is 
best  guarded  against,  while,  after  the  operation  is  over,  careful 
watching  and  judicious  nursing  are  more  needed  than  what  is 
strictly  called  medical  treatment. 

The  cyst-inflammation  is  a  still  more  serious  accident,  and  all 
the  more  from  its  occurring  when  least  expected,  though  it  is  cer- 
tainly much  less  likely  to  attack  simple  serous  cysts  than  growths 
of  a  more  compound  character,  and  those  especially  which  partake 
of  the  nature  of  alveolar  carcinoma.  Its  symptoms  are  seldom 
very  marked  at  the  outset,  and  the  pain  which  attends  it  is  by  no 


CYST-INFLAMMATION    AFTER    TAPPING.  449 

means  proportionate  to  the  clanger  of  the  attack.  Tenderness 
on  pressnre  over  the  tumor  is  indeed  always  evident,  and  some- 
times, when  the  inflammation  has  extended  to  the  peritoneum, 
there  is  likewise  severe  pain  independent  of  pressure;  but  a 
quickened  pulse,  a  general  febrile  condition,  unpreceded,  how- 
ever, by  shivering,  and  sickness,  are  the  signs  which  shouhl  at 
once  excite  our  apprehension.  Of  all  the  symptoms,  indeed, 
vomiting  and  an  irritability  of  stomach,  which  rejects  all  medi- 
cine, all  food,  all  drink,  though  the  thirst  is  usually  considerable, 
are  of  the  greatest  moment,  since  they  are  almost  pathognomonic 
of  this  affection.  It  seldom  comes  on  within  the  first  thirty-six 
hoars,  often  not  until  the  third  day  after  tapping;  while  the  rate 
of  its  progress  in  fatal  cases  is  variable;  death  sometimes  taking 
place  in  three  days  from  its  commencement,  in  other  instances 
not  till  after  the  lapse  of  a  week.  Whether  quick  or  slow,  how- 
ever, in  its  advance,  symptoms  of  an  acute  character  are  at  no 
time  well  marked;  the  pulse  seldom  has  much  power,  the  intense 
pain  often  attendant  on  peritonitis  is  absent,  the  bowels,  though 
constipated,  answer  tolerably  readily  to  medicine,  and  death 
usually  takes  place  under  the  symptoms  of  depression  which  ac- 
company pypemia. 

When  allowed  to  go  on  unchecked  for  twenty-four  or  thirty-six 
hours,  the  cyst-inflammation  is  I  believe  an  almost  hopeless  aflec- 
tion,  though  if  treated  quite  at  the  outset,  and  in  women  not  ex- 
hausted by  the  previous  ovarian  disease,  it  yields  tolerably  readily 
to  treatment.  Depletion  is  the  great  remedy  on  which  I  rely,  and 
local  depletion  usually  answers  every  end;  though,  on  one  occa- 
sion, when  the  symptoms  set  in  with  much  severity,  and  indeed 
more  nearly  resembled  those  of  acute  peritonitis  than  of  mere  in- 
flammation of  the  cyst,  I  abstracted  twelve  ounces  of  blood  from 
the  arm  Avith  great  benefit.  Twelve  or  eighteen  leeches,  however, 
ap})lied  over  the  tender  part,  and  followed  by  a  warm  poultice 
frequently  renewed,  or  by  perpetual  fomentation  by  means  of  the 
spongiopiline,  often  remove  the  pain,  abate  the  fever,  and  stop 
the  sickness.  So  long  as  the  last-named  symptom  continues,  no 
amount  of  improvement  in  other  respects  can  be  considered  satis- 
factory, and  whether  the  tenderness  seemed  to  call  for  it  or  not,  I 
should  repeat  the  depletion  if  the  sickness  had  not  ceased,  or,  at 
least,  were  not  greatly  mitigated.  A  single  large  dose  of  calomel, 
as  ten  grains  given  in  powder,  sometimes  arrests  the  irritability 
of  the  stomach,  and  obtains  the  action  of  the  bowels  with  the 
smallest  amount  of  general  disturbance.  The  less,  however,  that 
the  irritable  stomach  is  teased  with  medicines  the  better,  and  iced 
water  in  small  quantities,  or  little  pieces  of  ice  ^ivcn  to  the 
patient  to  suck,  are  by  far  the  best  means  of  relieving  the  sick- 
ness and  of  quenching  the  thirst.  When  the  more  serious  symp- 
toms are  passing  ofi",  a  few  spoonfuls  of  cold  beef-tea,  or  of  cold 
chicken  broth,  will  be  found  to  be  the  most  appropriate  food,  and 
that  which  the  stomach  will  best  support. 

To  see  the  patient  early,  to  watch  her  carefully,  so  as  to  be  ready 

21) 


450  PROCEEDINGS    FOR    PERMANENT 

witli  a  timely  repetition  of  the  depletion  if  the  symptoms  do  not 
yield  to  its  first  performance,  such  are  the  essentials  for  saving 
the  patient  from  this  disease,  in  the  management  of  which  no  time 
is  afforded  for  elahorate  treatment,  nor  any  chance  given  for  re- 
trieving lost  opportunities. 


LECTURE    XXIX. 

OVARIAN  TUMORS  AND  DROPSY. 

Treatment  continued.  Moasnres  proposed  for  the  radical  cure  of  ovarian  dropsy. 
Tapping  and  prossure.  Subcutaneous  puncture  of  the  cyst.  Tapping:  per 
vaginam.  Tapping;  followed  by  some  contrivance  for  keeping  tlie  wound  per- 
mancntl}-  open  ;  incision  and  partial  e.xcision  of  the  cyst.  Tapping,  with  in- 
jection of  iodine; — estimate  of  its  advantages  and  dangers.  Enumeration  of 
points  concerning  which  further  information  is  needed. 

Although  in  the  last  lecture  I  assigned  some  reasons  for 
douljting  whether  the  perils  attendant  on  tapping  in  ovarian  dropsy 
had  not  been  somewhat  overrated,  it  must  yet  l)e  allowed  that  the 
operation  very  rarely  indeed  proves  curative,  that  the  fluid  gen- 
erally re-collects,  and  that  a  reprieve,  and  commonly  hut  a  very 
brief  reprieve,  is  all  that  it  afl^brds  to  the  patient. 

Hence  have  arisen  various  modifications  of  the  operation  of 
tapping,  each  of  which  has  had  for  its  object  tlie  favoring  the 
contraction  of  the  cyst,  and  the  retarding,  if  not  the  preventing, 
the  reaccumulation  of  the  fluid. 

These  consist  of: 

1st.  The  employment  of  tight  bandaging  after  the  evacuation 
of  the  contents  of  the  cj^st. 

2d.  The  subcutaneous  puncture  or  incision  of  the  cyst,  with 
the  view  of  allowing  of  the  escape  of  its  contents  into  the  peri- 
toneal cavity,  and  of  thus  imitating  the  occurrences  which  take 
place  when  the  cyst  bursts  spontaneously. 

3d.  The  puncture  of  the  cyst  per  vaginam,  in  order  to  insure 
its  more  thorough  evacuation,  and  thereby  to  increase  the  chances 
of  its  permanent  contraction. 

4th.  The  keeping  the  cyst  constantly  empty,  either  by  allowing 
a  tube  to  remain  permanently  in  its  cavity,  or  by  rendering  the 
opening  into  it  fistulous. 

5th.  The  employment  of  medicated  injections  into  the  cavity 
of  the  cyst,  of  which  the  solutions  of  iodine  appear  to  be  the  least 
hazardous  as  well  as  the  most  frequently  successful. 

Each  of  tliese  proceedings  must  be  considered  in  succession. 

I.    Tight  bandaging  after  the  evacuation  of  the  contents  of  the  cyst. 

The  probable  utility  of  tight  bandaging  as  a  means  of  prevent- 
ing the  reaccumulation  of  the  fluid  of  an  ovarian  dropsy  after 


CURE    OF    OVARIAN    DROPSY.  451 

tapping  was  suggested  by  Mr.  Benjamin  Bell  ;^  and  the  late  Dr. 
Hamilton,'^  of  Edinburgh,  was  accustomed  to  apply  a  bandage 
moderately  tight  round  the  abdomen  as  an  adjunct  to  that  plan 
of  percussion  of  the  cyst  from  which  he  believed  that  in  some 
instances  he  had  obtained  very  remarkable  results.  Mr.  Baker 
Brown,^  however,  was  the  first  who  proposed  its  systematic  em- 
ployment as  a  means  of  preventing  the  growth  of  ovarian  cysts  or 
their  refilling  after  tap[)ing.  In  his  original  communications  on 
the  subject,  he  proposed  to  combine  the  free  use  of  mercurials  and 
of  active  diuretics  with  the  local  treatment,  but  subsequently  aban- 
doned their  use,  and  has  since  restricted  himself  to  the  application 
of  firm  pressure  over  the  tumor.  His  mode  of  applying  it  will  be 
best  described  in  his  own  words.^ 

"  First  of  all,  compresses  of  linen  or  lint  should  be  so  arranged 
as  to  present  a  convex  surface,  adapted  as  nicely  as  possible  to  the 
concavity  of  the  pelvis.  Over  these  compresses  straps  of  adhesive 
plaster  should  be  applied,  so  as  to  embrace  the  spine,  meeting 
and  crossing  in  front,  and  be  extended  from  the  vertebral  articu- 
lation of  the  eighth  rib  to  the  sacrum.  Over  this  strapping  either 
a  broad  flannel  roller,  or,  still  better,  a  band  with  strings  and  loops 
which  tie  in  front,  may  be  applied ;  or  a  well-made  bandage,  which, 
by  lacing  in  front,  may  be  gradually  tightened,  as  made  at  my  sug- 
gestion by  Mr.  Spratt,  2  Brook  Street.  These  bandages  must  be 
prevented  from  slipping  upwards  by  a  strap  around  each  thigh. 
Both  the  compresses  and  the  bandages  will  require  watching 
and  adjusting  from  time  to  time,  lest  by  unequal  pressure  the 
bowels  or  bladder  be  subjected  to  inconvenience.  Also  the  crest 
of  the  ilium  should  be  guarded  with  thick  bufl:alo  skin  or  amadou 
plaster." 

This  proceeding  is  recommended  as  especially  applicable  for 
cases  of  simple  ovarian  cysts,  free  from  adhesions,  with  clear  and 
not  albuminous  contents,  and  when  time  and  the  condition  of  the 
patient  admit  of  its  persevering  employment.  Such,  liowever, 
are  the  very  cases  in  which  there  is  the  greatest  probability  of 
the  spontaneous  cure  of  the  disease,  of  which  two  instances  after 
a  single  tapping  have  come  under  my  own  observation.  If  to 
this  fact  we  likewise  add  the  small  number  of  the  reported  cures 
efi'ected  by  this  means,  and  the  circumstance  that  the  reality,  or 
at  any  rate  the  permanence,  of  some  of  them  is  more  than  doubt- 
ful, we  can,  I  think,  come  to  no  other  conclusion  than  that  the 
curative  power  of  compression  of  the  cyst,  cither  before  or  after 
the  evacuation  of  its  contents,  is  not  at  all  established. 

At  the  same  time,  however,  there  can  be  no  doubt  but  that  the 
enlargement  or  the  refilling  of  an  ovarian  cyst  may  be  much  re- 
tarded by  the  patient  constantly  wearing  a  well-adjusted  bandage, 

1  Systetn  of  Siirgery,  vol.  v,  p.  24G. 

'■*  Practical  Ohservaiions  on  Midwifcnj,  8vo.,  2d  cd.,  luliiibur;:;li,  1840,  p.  02. 
»  At  first  in  the  Lancet,  and  afterwards  in  his  wortc  on  Diseases  of  Women,  &c. 
8v().,  1854,  p.  213. 
<  Op.cit.,  p.  212. 


452  PROCEEDINGS    FOR    PERMANENT 

though  it  is  obvious  that  no  kind  of  compress  and  bandage,  how- 
well  soever  they  maybe  adjusted,  can  do  more  than  interfere  with 
its  rising  above  the  pelvic  brim,  that  they  cannot  press  upon  it  at 
all  until  it  has  acquired  a  certain  magnitude,  which,  if  not  con- 
siderable, is  yet  quite  sujB&cient  to  render  the  mere  mechanical 
obliteration  of  its  cavity  ahnost  or  altogether  impossible.  In 
some  instances  it  is  probable  that  inflammation  of  the  cyst  may 
be  excited  by  very  firm  pressure,  and  that  thus  adhesion  between 
its  w^alls  and  a  permanent  cure  ma}'  be  eflected ;  but  such  cases 
must  be  exceptional,  are  probably  very  rare,  and  no  such  result 
can  be  calculated  on  as  at  all  likely  to  take  place  from  mere  com- 
pression. 

II.  It  has  been  suggested  that  an  attempt  should  be  made  by 
the  subcutaneous  pimcture  of  the  dropsical  ovarium  to  imitate  na- 
ture's own  proceed  nigs  when  the  cyst  gives  way,  and  pours  out 
its  contents  into  the  peritoneal  cavity. 

This  is,  however,  a  suggestion  on  theoretical  grounds,  rather 
than  a  mode  of  treatment  which  has  been  brought  to  the  test  of 
actual  experiment.'  Its  expediency  turns  in  part  on  the  answer 
(at  present  by  no  means  an  encouraging  one)  to  be  given  to  the 
inquiry  as  to  the  danger  to  life  attendant  on  the  spontaneous 
rupture  of  ovarian  cysts.  But  it  must  also  not  be  forgotten  that 
while  very  often  fatal,  the  accident  has  in  a  large  proportion  of 
the  cases  where  the  patients  survived,  been  followed  by  the 
speedy  re-collection  of  the  fluid.  Moreover,  by  the  subcutaneous 
puncture  of  the  cyst  we  should  empty  into  the  peritoneal  cavity 
fluid  of  the  nature  of  Avhich,  and  the  probability  of  its  exciting 
serious  inflammation,  we  must  be  almost  entirely  ignorant.  The 
direct  puncture  of  the  cyst  through  the  abdominal  w'alls  in  order 
to  ascertain  this  point,  would  at  once  deprive  the  operation  of 
what  has  been  alleged  as  its  chief  recommendation,  namely  the 
avoidance  of  any  communication  between  the  interior  of  the  cyst 
and  the  external  air. 

m.  The  puncture  of  the  cyst  through  the  vagina  instead  of  through 
the  abdominal  walls,  has  been  advocated  as  a  means  of  insuring 
the  more  complete  evacuation  of  the  fluid,  and  consequently  of 
increasing  the  probabilities  of  a  permanent  cure. 

The  question  of  the  advantages  of  this  proceeding  turns,  I 
apprehend,  very  much  on  the  view  taken  of  the  expediency  of 
early  tapping.  In  the  case  of  an  ovarian  cyst  which,  though  still 
small,  though  smooth,  elastic,  and,  as  far  as  can  be  ascertained, 
simple  in  its  character,  is  yet  obviously  increasing,  tapping  per 
vagi  nam  appears  to  me  to  have  the  advantages  of  completely 
emptying  the  cyst,  of  excluding  the  admission  of  air,  ajid  of 
wounding  the  peritoneum  in  a  situation  wdiere,  as  far  as  I  have 
seen,  wounds  are  less  often  resented  than  when  inflicted  higher 

'  Dr.  Tilt,  indeed,  Lancet,  Aug.  5,  1848,  p.  14G,  mentions  an  instance  in  which 
it  was  adopted  with  success  under  the  direction  of  M.  Kecamier,  but  I  am  not  aware 
of  any  other  case  in  which  this  proceeding  was  attempted. 


CURE  OF  OVARIAN  DROPSY.  453 

in  the  abdominal  cavity.  On  the  other  hand,  for  the  following 
reasons,  I  do  not  think  the  proceeding  expedient  in  cases  where 
the  tumor  has  attained  any  considerable  size. 

1st.  Because  the  cyst,  when  large,  sometimes  prevents  the 
bladder  from  rising  out  of  the  pelvic  cavity.  The  organ  conse- 
quently becomes  much  altered  in  shape,  and  it  is  spread  out 
laterally  in  such  a  way  as  to  expose  it  with  no  very  great  unskil- 
fulness  on  the  part  of  the  operator  to  the  risk  of  injury  by  the 
trocar. 

2d.  In  the  case  of  all  compound  cysts,  the  larger  are  commonly 
those  which  are  distinguishable  in  the  abdominal  cavity,  the 
snihller  cysts  and  the  greater  proportion  of  solid  matter  are  to  be 
found  near  its  pedicle.  Hence  a  puncture  per  vaginam  is  likely, 
in  these  circumstances,  to  prove  less  efficacious  than  tapping  the 
cyst  through  the  abdominal  walls. 

3d.  The  risk  of  hemorrhage  from  wounding  some  large  vessel 
is  greater  when  the  puncture  is  made  near  the  pedicle  of  the 
tumor.  Except  in  those  cases,  therefore,  where  the  cyst  is  very 
small,  or  where  it  is  proposed  to  follow  up  the  puncture  by  some 
further  proceeding,  it  is  not  desirable  to  deviate  from  the  ordinary 
mode  of  tapping. 

IV.  It  has  been  recommended  to  keep  the  cyst  constantly  empty^ 
either  by  means  of  a  tube  retained  permanently  in  its  cavity,  or 
by  rendering  the  opening  into  it  fistulous. 

As  one  of  the  great  drawbacks  from  the  simple  puncture  of  an 
ovarian  cyst  consists  in  the  rapidity  with  which  the  fluid  rcaccu- 
mulates,  so  nothing  would  seem  a  more  obvious  means  of  ])rcvent- 
ing  this  evil  than  keeping  the  opening  permanent.  The  idea,  in- 
deed is  as  old  as  Celsus,'  who  gives  veiy  detailed  directions  for 
fixing  a  leaden  or  copper  tube  in  the  wound,  and,  after  partly 
evacuating  the  fluid,  closing  its  orifice,  and  then  allowing  the  daily 
escape  of  about  half  a  pint  at  a  time  till  it  is  entirely  drained  away. 
The  directions  of  Celsus  apply,  indeed,  to  cases  of  ascites,  for  the 
distinction  between  it  and  encysted  dropsy  was  not  then  under- 
stood ;  and  to  this  circumstance  it  is  probably  in  some  measure  to 
be  attributed  that  like  many  other  suggestions  of  the  old  writers 
it  remained  unnoticed.  In  the  middle  of  the  eighteenth  century, 
however,  the  celebrated  Frencli  surgeon,  Le  Dran,^  adopted  a  some- 
what similar  proceeding.  His  operation,  indeed,  was  a  much  more 
formidable  one  than  that  of  Celsus,  inasmuch  as  he  enlarged  the 
opening  into  the  ovarian  sac  to  the  extent  of  four  inches,  then  in- 
troduced into  it  a  leaden  tube  of  considerable  size,  and  at  length, 
after  a  hazardous  suppuration  had  continued  for  some  time,  the 

1  De  MeAlcind,,  lib.  vii,  cap.  xv.  See  page  362  of  Milligan's  edition,  Edinburgh, 
1881.  jVI}'  attention  was  called  to  this  passage  by  Fock's  extremely  able  pajier  on 
the  operative  treatment  of  ovarian  cysts,  in  Munatsclirift  f.  Gehurtskinidc,  vol.  vii, 
p.  332,  wliich  contains  a  good  critique  on  Uie  comparative  merits  of  various  pro- 
ceedings. 

2  Memnires  de  V Academie  Royale  de  Chirurgle,  tome  vi,  12mo.,  Paris,  1853,  pp. 
51  and  73. 


454  PROCEEDINGS    FOR    PERMANENT 

patient  recovered,  though  in  all  cases  but  one  a  permanently  fis- 
tulous opening  into  the  cyst  was  left  behind.  Isolated  instances 
are  to  be  found  from  that  time  in  the  medical  journals,  in  which, 
purposely  or  by  accident,  the  opening  into  an  ovarian  cyst  had 
remained  unclosed,  and  the  consequent  suppuration  had  been 
followed  by  the  contraction,  or  even  by  the  complete  obliteration 
of  its  cavity.  It  is,  however,  only  within  the  past  twenty  years 
that  any  systematic  attempts  have  been  made  to  carry  this  idea 
into  practice,  as  a  means  of  effecting  the  radical  cure  of  ovarian 
dropsy  in  cases  not  amenable  to  other  modes  of  treatment,  or  in 
which  their  employment  is  shrunk  from  as  being  too  hazardous. 

There  are  three  different  modes  by  which  it  has  been  endeavored 
to  obtain  the  contraction  or  obliteration  of  the  cyst. 

1st.  By  leaving  a  tube  in  the  aperture  formed  after  tapping 
through  the  abdo'minal  walls,  or  by  stitching  the  edge  of  the  cyst 
wound  to  that  of  the  integuments  so  as  to  keep  the  opening  per- 
manently fistulous. 

2d.  By  tapping  per  vaginam,  and  securing  a  tube  in  the 
opening, 

3d.  By  excising  a  portion  of  cyst- wall,  either  with  or  without 
subse(pient  closure  of  the  external  wound. 

All  these  proceedings  have  this  in  common  :  that  the  inflam- 
mation, and  more  or  less  complete  destruction  of  the  cyst,  or  at 
least  of  its  secreting  membrane,  is  the  condition  of  their  success, 
while  their  common  danger  arises  from  the  difficulty  of  restraining 
that  inflanmiation  within  safe  bounds.  Kone  of  them  have  been 
resorted  to  suflicicntly  often  to  furnish  any  trustworthy  body  of 
statistics  illustrative  of  their  results  ;  but  the  cases  related  by  Mr. 
Baker  Brown, ^  who  is  an  advocate  of  their  performance,  plainly 
show  the  nature  and  the  amount  of  the  hazard  to  which  the  pa- 
tient is  exposed.  My  own  experience  of  the  first  of  these  opera- 
tions is  derived  from  two  cases,  in  both  of  which  an  exploratory 
incision  had  been  nuide  with  the  intention,  had  not  the  unexpected 
presence  of  adhesions  prevented  it,  of  extirpating  the  cyst.  The 
cases  had  a  fatal  issue,  which  took  place  in  one  instance  in  the 
course  of  ninety-six  hours,  the  patient  dying  apparently  exhausted 
by  the  profuse  sero-purulcnt  discharge.  Xo  tube  was  introduced 
either  in  this  or  in  the  other  case ;  but  the  edges  of  the  cyst  were 
simply  stitched  to  those  of  the  integuments  in  the  first  case,  while 
in  the  second  the  opening  remained  fistulous  of  its  own  accord. 
In  that  instance  the  cyst  was  multilocular,  with  a  considerable 
amount  of  solid  matter.  Life  was  prolonged  for  seventeen  days, 
during  which  the  symptoms  were  those  of  exhaustion,  gradually 
increasing,  but  unattended  by  any  apparent  suflering.  The  dis- 
charge from  the  cyst  was  horribly  offensive,  and  the  washing  it 
out  ^n  several  occasions  with  tepid  water  had  no  influence  in 
modifying  this  condition.  After  death  the  same  kind  of  morbid 
appearances  was  observed  in  both  cases,  namely,  cyst-inflammation, 

1  O/J.  ciL,  pp.  227  and  237. 


CURE    OF    OVARIAN    DROPSY.  455 

with  great  softening  of  its  wall,  a  deposit  of  lymph  on  its  interior, 
and  some  peritonitis,  which,  however,  in  the  first  case  was  not  of 
recent  date.  In  neither  instance  was  there  more  than  a  very  small 
quantity  of  pus  within  the  cyst,  and  I  suppose  that  if  tlie  opening  be 
moderately  free,  the  pressure  of  the  surrounding  viscera  will  keep 
the  sac  nearly  empty.  It  has,  indeed,  been  })roposed,  in  order  to 
obviate  all  risk  of  the  accumulation  of  the  contents  of  the  cyst 
within  its  cavity,  that  the  patient  should,  as  far  as  possible,  ob- 
serve the  prone  position,  or  that  the  incision  into  the  cyst  should 
be  made  in  the  linea  semilunaris,  a  practice  adopted  by  Mr.  Brown, 
or  in  the  lateral  region  in  the  situation  of  a  line  drawn  from  the 
last  rib  to  the  iliac  crest,  as  vei-y  strenuously  urged  by  the  late  Dr. 
Blihrino;,  of  Berlin.^ 

Ihe  danger  of  the  proceeding  does  not  appear  to  be  of  a  kind 
which  any  modification  in  tlie  seat  of  the  opening  would  remove,  or 
perhaps  even  much  lessen.  Still  this  point  is  one  not  altogether  to 
be  lost  sight  of,  since  to  the  circumstance  of  the  more  eligible 
situation  of  the  opening  in  cases  where  the  puncture  is  made  [)er 
vaginam  must  be  attributed,  in  part,  the  more  favorable  results 
which  have  followed  that  operation. 

The  great  advocate  of  the  puncture  per  vaginam  was  the  late 
Professor  Kiwisch,^  whose  colleague  and  successor,  Professor  Scan- 
zoni,  of  Wlirzburg,  s[)eaks  of  the  proceeding  in  terms  scarcely  less 
eulogistic.  The  former,  indeed,  gives  no  data  from  which  the. 
exact  proportion  of  successes  to  failures  can  be  arrived  at  (an 
omission  which  in  many  other  instances  detracts  from  the  value  of 
his  statements),  but  Professor  Scanzoni^  gives  a  very  clear  account 
of  the  results  which  he  has  obtained,  and  they  are  wonderfully 
favorable.  'lie  says  that  in  8  out  of  14  cases  a  perfect  cure  followed 
the  operation  ;  that  in  2  the  fluid  re-collected  in  the  course  of  a 
few  weeks  ;  that  1  died  of  tyi)lius  fever  two  months  afterwards,  and 
that  3  patients  were  lost  sight  of;  but  that  in  no  instance  did  death 
take  place  from  the  immediate  effects  of  the  operation.  At  the 
same  time,  however,  he  admits  the  possibility  of  such  an  occur- 
rence, and  mentions  the  case  of  a  young  wonum,  aged  nineteen, 
who  died  of  extensive  peritonitis  a  few  days  after  the  performance 
of  this  operation  on  her  by  Professor  Kiwisch.  For  some  reason, 
too,  which  he  does  not  assign,  even  this  amount  of  supi)osed 
success  has  apparently  been  insufiicient  to  induce  Scanzoni  to  per- 
severe in  this  proceeding,  since  the  third  edition  of  his  valuable 
work  on  Diseases  of  Women,  published  at  the  end  of  18G3,  contains 
no  reference  to  any  fresh  cases,  but  a  mere  textual  re[)rint^  of  the 
facts  contained  in  the  second  edition,  which  appeared  six  j'cars 
before. 

It  always  appeared  to  me  that  an  unnecessary  degree  of  violence 

1  Die  Heihing  der  Eier stock ffesrhwulste,  8vo.,  Berlin,  1848. 

*  At  first  in  tlie   Prager  Vlerteljahrschrift,  vol.  x.  p.  87  ;  and   iiftorwards  in  liis 
work,  to  wliich  rtderence  has  so  often  been  made.    See  vol.  ii,  \\.  102. 
3  Op.  cit,  i>.  406.  *  Op.  cit.,  3d  ed.,  p.  402. 


456  TAPPING    PER    VAGINAM, 

was  inflicted  on  the  cyst  by  the  operation  as  practised  by  Kiwisch. 
He  tapped  the  cyst  per  vaginani  once  in  order  to  ascertain  that 
the  cyst  was  a  simple  one,  a  proceeding  which,  thongh  it  involves 
a  dehay  of  some  weeks,  is  certainly  expedient  in  every  case  of 
ovarian  dropsy,  since  now  and  then  the  fluid  does  not  re-collect, 
and  it  is  always  desirable  to  give  the  patient  that  chance,  even 
though  it  be  but  slender.  So  soon  as  the  fluid  had  re-collected 
sufficiently  to  allow  of  the  repetition  of  the  puncture,  the  patient 
being  placed  in  a  semi-recumbent  posture,  her  feet  resting  on  two 
stools,  and  her  knees  separated  by  assistants,  a  small  canula,  curved 
so  as  to  correspond  with  the  axis  of  the  pelvis,  was  carried  along 
the  fingers  and  introduced  through  the  roof  of  the  vagina  into  the 
cyst.  "When  but  a  small  quantity  of  fluid  had  escaped,  a  grooved 
director,  curved  so  as  to  correspond  with  tlie  canula,  was  intro- 
duced through  it,  and  the  canula  then  Avithdrawn.  A  narrow 
probe  pointed  bistoury  was  then  carried  along  the  director,  and 
the  wound  enlarged  so  as  to  admit  the  index  finger  to  examine 
the  interior  of  the  cyst,  and  to  allow  of  the  ready  escape  of  its 
contents.  A  metal  tube  of  the  thickness  of  the  thumb,  terminat- 
ing in  a  rounded,  slightly  bulbous  extremity,  was  next  introduced 
into  the  cyst,  and  retained  there  by  a  T  bandage.  Professor  Scan- 
zoni  adopts  a  similar  plan,  though  he  employs  a  straight  trocar 
instead  of  one  curved  like  that  of  Kiwisch,  and  leaves  the  silver 
, canula  in  the  wound,  which  he  does  not  enlarge,  unless  the  con- 
tents of  the  cyst  are  too  thick  to  flow  out  readily,  in  which  case 
he  enlarges  the  opening  by  a  long  handled  knife  with  a  blade  an 
inch  and  a  half  long,  which  he  introduces  through  the  canula  for 
this  purpose. 

In  the  three  cases  in  which  I  performed  this  operation,  and 
which  were  carefully  selected  as  suitable  for  it,  I  employed  a 
trocar  and  canula  having  a  curve  like  that  of  Kiwisch's  instru- 
ment, and  nearly  as  big  round  as  the  little  finger.  Through  the 
canula  a  long  elastic  tube  of  the  size  of  a  Xo.  12  catheter  was 
introduced,  and  the  canula  was  withdrawn  over  it,  while  the  tube 
was  easily  retained  in  the  cyst  by  carrying  it  through  a  little  silver 
collar  in  which  it  was  fixed  by  a  screw,  the  collar  itself  being  at- 
tached to  a  framework  such  as  used  to  be  employed  for  retaining 
the  uterine  supporter  in  its  place,  and  secured  in  a  similar  manner 
by  tapes  passing  round  the  pelvis  and  thighs  t>f  the  patient. 

My  belief  is,  that  the  operation  thus  modified  in  its  details  is 
attended  by  less  discomfort,  and  also  by  a  smaller  amount  of  risk, 
than  -when  an  incision  is  made  into  the  cyst  and  a  heavy  metallic 
tube  afterwards  fixed  in  the  opening.  Be  this  as  it  may,  however, 
the  proceeding  has  appeared  to  me  to  be  attended  by  much  more 
hazard  than  would  be  inferred  from  the  language  of  Kiwisch  or 
Scanzoni.  The  death  of  one  of  my  patients  Avas,  indeed,  not  due 
to  causes  necessarily  connected  with  the  operation ;  but  in  the 
other  two,  who  eventually  recovered,  the  symptoms  of  inflamma- 
tion beginning  in  the  cyst  and  extending  to  the  peritoneum  were 
so  formidable  that  their  life  was  for  some  thirty-six  hours  in  most 


AND    WOUND    KEPT    OPEN.  457 

imminent  clanger,  and  most  active  local  depletion  was  needed  to 
subdue  the  mischief.  Scanzoni,  indeed,  says  that  in  some  of  his 
cases  no  symptoms  of  reaction  followed  the  operation,  nor  any 
signs^of  local  inflammation,  but  the  tumor  gradually  diminished 
in  size,  and  in  the  course  of  a  few  days  all  discharge  had  ceased, 
so  that  the  canula  was  sometimes  withdrawn  as  early  as  the  eighth 
or  tenth  day,  or  even  sooner.  Both  he  and  Kiwisch,  however,  speak 
of  the  general  occurrence  of  severe  cyst-inflammation,  during  the 
continuance  of  which  a  thin  or  sanious  discharge  is  poured  out, 
and  the  local  tenderness  is  extreme.  Kiwisch  speaks  of  the  grad- 
ual subsidence  of  these  symptoms  in  from  ten  to  twenty  days,  and 
of  the  discharge  then  gradually  assuming  a  puriform  character, 
but  not  Anally  ceasing  until  from  Ave  to  seven  weeks,  previous  to 
which  it  is  not  prudent  permanently  to  withdraw  the  tube.  During 
this  time  the  cyst  should  be  often  syringed  out  gently  with  tepid 
water,  and  I  believe  the  direction  that  this  should  be  done  twice  a 
day  is  very  judicious.  I  may  also  add  that  if  an  elastic  tube  be 
employed,  that  will  require  to  be  changed  every  five  or  six  days, 
and  I  have  been  compelled  by  the  contraction  of  the  opening  to 
dilate  it  by  means  of  a  sponge  tent  introduced  for  a  few  hours, 
before  it  would  readmit  a  tube  as  large  as  that  which  had  previ- 
ously been  placed  there. 

The  one  great  peril  of  this  operation  seems  to  be  the  cyst-in- 
flammation, and  this  surmounted,  the  risk  of  the  hectic  symptoms 
occurring,  of  pyiemia  and  its  consequences,  does  certainly  seem 
to  be  much  smaller  than  when  the  puncture  is  made  in  the  ab- 
dominal walls.  The  most  energetic  antiphlogistic  and  depletory 
treatment  afibrd  the  only  chance  of  subduing  the  cyst-inflamma- 
tion ;  and  if  very  formidable,  and  not  yielding  at  once  to  treat- 
ment, it  would  of  course  be  our  duty  to  withdraw  the  tube  and  to 
postpone  the  attempt  at  curing  the  disease  to  the  more  pressing 
necessity  of  preserving  the  patient's  life. 

I  ought  to  add  that  the  results  of  the  operation  were,  on  the 
whole,  satisfactory  in  the  two  patients  who  survived  its  perform- 
ance. I  lost  sight  of  one,  however,  within  two  months  after  her 
discharge  from  the  hospital,  though  uj)  to  that  time  the  fluid  had 
not  re-collected.  The  other  patient  continues  now,  after  the  lapse 
of  twelve  years,  in  very  tolerable  health,  and  stands  all  day  to 
serve  in  a  confectioner's  shop.  Iler  case  was  one  of  flxt  cyst  of 
the  ovary,  consequently  not  one  in  which  its  complete  obliteration 
was  likely  to  occur.  Nor,  indeed,  did  this  happen,  but  an  open- 
ing into  the  C3'st  remained  fistulous,  and  from  .^iij  to  .^vi  of  puru- 
lent matter  escaped  thus  almost  every  day  for  several  years,  while 
if  the  discharge  for  a  day  or  two  became  very  scanty,  headache 
occurred,  and  the  patient  felt  various  discomforts,  which  again 
ceased  on  the  reappearance  of  the  wonted  secretion.  About  four 
years  since,  however,  all  discharge  ceased,  and  an  ill-defined  solid 
mass,  the  size  of  an  orange,  behind  the  uterus,  is  now  the  only 
evidence  of  her  previous  disease. 

Whatever  may  be  thought  of  tlie  advantages  of  this  operation, 


458  DANGER    OF    CYST-INFLAMMATION 

it  is  not  possible  to  adopt  it  in  a  very  large  number  of  cases,  since 
the  ovarian  ejst  often  rises  at  a  comparatively  early  period  out  of 
the  pelvic  cavity.  In  many  others,  also,  it  is  clearly  inexpedient, 
since  in  none  but  simple  cysts  is  cure  by  this  method  possible. 
In  the  case  of  a  small  simple  cyst,  however,  it  appears  to  me  more 
than  doubtful  whether  we  are  justified  in  exposing  a  patient  to  a 
danger  so  very  formidable  as  that  of  the  cyst-inflammation  which 
this  operation  almost  invariably  provokes.  At  any  rate,  we  can- 
not, I  think,  rest  satisfied  with  a  proceeding,  the  indications  for 
which  must  be  furnished  b}^  some  purely  exceptional  conditions, 
but  must  carry  our  inquiries  further  after  some  measures  more 
certain,  or  more  safe. 

The  dano-ers  which  attend  on  the  incision  of  ovarian  cvsts,  or 
on  any  attempt  to  keep  the  puncture  made  in  tapping  perma- 
nently fistulous,  accompany  in  a  still  greater  degree  the  excision 
of  a  portion  of  the  cynt-wall.  No  instance  of  the  performance  of  this 
operation  has  come  under  my  own  notice,  but  several  cases  are 
reported  in  the  medical  journals  both  of  its  successful  and  its  non- 
successful  employment.  In  some  instances  it  was  had  recourse 
to  in  consequence  of  unexpected  adhesions  preventing  the  com- 
plete removal  of  the  tumor,  as  in  the  patients  operated  on  by 
Martini,'  Biihring,^  Poland,^  Prince,''  and  Atlce,*  of  whom  4  died 
and  3  recovered.  But  it  has  also  been  selected  in  cases  of  thin- 
walled  cysts,  uncomplicated  with  adhesions,  and  existing  in  pa- 
tients whose  health  was  but  little  inq>aired,  on  the  sui)p()sition 
that  partial  excision  might  be  found  to  be  a  less  hazardous  oi)era- 
tion  than  total  extirpation  of  a  cyst.  In  such  or  such-like  condi- 
tions, the  operation  has  been  performed  by  Mr.  Wilson,  of  Bris- 
tol," Mr.  Brown,  of  London,^  and  Mr.  Crouch;^  and  of  these  6 
cases,  2  terminated  fatally,  4  had  a  favorable  issue.  One  of  the 
patients  died  from  hemorrhage,  the  other  from  exhaustion  and  the 
effusion  of  purulent  matter  from  the  cyst  into  the  peritoneal  cavity; 
while  so  alarming  were  the  sj'mptoms  of  inflammation  iu  one  of 
Mr.  Brown's  cases,  that  it  was  considered  necessary  to  bleed  the 
patient  from  the  arm  four  times  in  the  first  forty-eight  hours  after 
the  operation. 

The  existence  of  adhesions  such  as  prevent  the  complete  extir- 
pation of  an  ovarian  cyst  may  possibly  justify  the  incision  into  it, 
and  the  allowing  the  escape  of  its  contents,  though  it  is  douljfful 
whether  the  risks  of  this  proceeding  do  not  outweigh  the  proba- 
bilities of  success.  The  excision  of  a  portion  of  the  cyst,  and  the 
return  of  the  remainder  into  the  abdominal  cavity,  rest  for  their 

'  Bust's  Magazin,  vol.  xv,  p.  436. 

'  Op.  cit.,  cases  vii  and  viii,  pp.  37  and  43. 

8  Gki/'s  Hospital  Reports,  3d  series,  vol.  i,  p.  63. 

*  Awericaji  Journal,  July  1850,  vol.  xlv,  p.  207. 

6  Ibid.,  April  1855,  p.  387.     Nos.  9,  12,  and  13,  in  his  table. 

6  Provincial  Medical  Journal,  1851,  p.  33.  ">  Op.  cit.,  p.  235. 

®  Association  Medical  Journal,  p  60.  In  this,  unlike  the  others,  the  cyst-wall 
was  of  very  considerable  thickness.  It  is  worth  notice,  too,  that  no  fewer  than 
seventeen  small  arteries  required  ligature. 


FROM    THESE     PROCEEDINGS.  459 

justification  on  the  assumption  that  the  fluid,  unchano;ecl  by  the 
grave  injury  inflicted  on  the  cyst,  will  be  absorbed  by  itlie  perito- 
neum,—that  tlie  cyst  itself  will  continue  for  but  a  short  time  to 
secrete,  and  will  then  become  altered  in  character,  and  probably 
calcified.  We  need,  hoAvever,  some  guarantee  of  the  prolial)ility 
of  this  occurrence  usually  taking  place,  some  evidence  that  the 
excision  of  a  large  portion  of  the  cyst  is  not  likely  to  be  followed 
by  very  acute  inflammation  of  that  which  is  left  behind,  that  the 
secretion  from  it  will  not  become  sanious  or  purulent,  and  conse- 
quently will  not  be  likely  to  excite  violent  peritonitis.  At  }iresent 
we  have  no  grounds  for  such  expectations,  and  consequently  no 
encouragement  to  imitate  this  jiroceeding,'  which  seems,  indeed, 
now  to  have  fallen  into  well-merited  disuse. 

Y.  The  employment  of  iodine  injections  into  the  cavity  of  the  cyst 
with  the  view  of  preventing  the  reaccumulation  of  the  fluid. 

In  many  of  the  cases  to  which  reference  has  hitherto  been  made, 
injections  into  tlie  cyst  were  employed  either  for  the  pur|iose  of 
more  completely  evacuating  its  contents,  or  with  the  view  of  excit- 
ing such  a  measure  of  active  inflammation  of  its  walls  as  should 
lead  more  quickly  or  more  surely  to  the  obliteration  of  its  cavity. 
In  all  these  instances  the  injections  were  but  subsidiary  measures, 
neither  much  relied  on  by  the  operators,  nor  to  which  any  great 
sliarc  in  producing  the  patient's  recovery  (where  recovery  did  take 
place)  could  be  attributed.  Of  late  years,  however,  the  attempt 
has  been  made  to  destroy  the  secreting  power  of  the  cyst  by  the 
injection  into  it  of  a  solution  of  iodine,  a  practice  suggested  by  the 
success  of  a  similar  mode  of  treating  hydrocele  first  adopted  by 
Sir  Kanald  Martin  and  M.  Velpeau.  The  first  reported  cases  of 
tlie  employment  of  iodine  injections  in  ovarian  cysts  were  pub- 
lished by  M.  Thomas  in  1851;^  though  M.  Boinet,^  Avho  is  so 
strong  an  advocate  of  the  measure,  first  put  it  in  practice  in  the 
year  1848.  Since  that  time  it  has  been  repeatedly  had  recourse  to 
both  in  this  country  and  on  the  continent,  and  the  results  hitherto 
obtained  lead  to  the  hope  that  in  a  very  large  proportion  of  cases 
it  will  be  found  to  check  the  reaccumulation  of  the  fluid,  and  in 
many  instances  to  prevent  it  com[)letel3%  while  it  appears  to  be 
attended  by  less  serious  danger  than  any  other  operation  for  the 
radical  cure  of  ovarian  dropsy.  Some  of  the  advocates  of  its  em- 
ployment, indeed,  represent  the  injection  of  iodine  as  being  less 
hazardous  than  tapping  unaccompanied  by  it;  but  we  may  hesitate 
to  accept  this  conclusion  till  the  statements  concerning  it  are  more 
definite  than  the  alleged  results  of  "  twenty  or  thirty  "  cases.''    The 

1  A  judgment  still  more  unfiivoralilt!  to  tliis  procct'diiii;  has  hccii  jmsscd  byFock, 
in  his  able  critique,  pp.  362-807  ;  and  in  even  more  unqualilied  terms  by  Scunzoni, 
op.  cif.,  |).  470. 

*  J{f'i;ie  Med.  Chir.,  Feb  ,  ]8r,l  ;  and  Schmidt's  Jnhrh.,  1851,  No.  vi,  p.  327. 
»  ludoilternpie,  &c.,  8vo.,  Paris,  lHr,.5,  p.   4'J'.I. 

*  Dr.  Simpson,  in  Lnncci,  March  'Jl,  1857,  says  tl)at  only  one  death  occurred  in 
twenty  or  thirty  cases  in  whicii  he  had  used  the  injections  of  iodine.  Sinijuiarly 
enoutjh,  this  statement  apjiears  in  a  paper  devoted  Id  a  defence  of  statistics.  His 
Lecture  in  the  Medirnl  Times  for  Jan.  '28,  18G0,  is  e<pially  vague,  fur  he  speaks 
there  of  forty  or  fifty. 


460  CURE    OF    OVARIAN    DROPSY 

only  statistics  with  which  we  are  yet  furnished  sufficient  in  number 
and  in  apparent  exactness  to  warrant  any  conchision  being  drawn 
from  them,  are  those  of  M.  Boinet/  who  has  published  the  results 
of  45  operations  on  44  patients,  one  having  had  two  cysts,  which 
were  tapped  and  injected  at  different  times : 


Age  of  Patients. 

Cases. 

Cures. 

Failures. 

Deaths. 

'rom  15  to  20  years, 

2 

1 

1 

0 

"      20  "  80 

7 

5 

1 

1 

"      30  "  40 

17 

16 

0 

1 

"      40  "  50 

11 

6 

2 

3 

'<      50  "  60 

5 

2 

0 

3 

'«      60  "  78 

3 

1 

1 

1 

45  31  5  9 

In  34  of  the  cases  the  cj'sts  were  simple;  in  11  compound.  All 
the  successes  occurred  where  the  cyst  was  simple ;  but  3  deaths 
also  followed  the  injection  of  simple  cysts.  All  the  operations  on 
compound  cysts  failed;  and  6  of  them  were  followed  by  the  pa- 
tients' death  ;  though  certainly  in  many  of  these  cases  death  would 
have  taken  place  as  soon,  possibly  even  sooner,  if  interference 
had  not  been  resorted  to.  In  19  of  the  45  cases  the  puncture  and 
injection  were  employed  only  once,  and  in  16  of  the  number  a 
permanent  cure  was  obtained. 


19  injected 

once, 

16 

were  cured. 

2 

failures, 

1  death, 

7        " 

twice. 

5 

1 

" 

1      " 

6       " 

thrice. 

4 

1 

<i 

1      " 

42       a 

four. 

2 

1 

(( 

1      " 

4        " 

six, 

2 

0 

(1 

2      " 

2       " 

seventeen, 

1 

0 

11 

1      " 

2       '< 

nine. 

0 

0 

(1 

2      " 

The  whole  of  M.  Boinet's  paper  deserves  an  attentive  perusal; 
for  even  after  every  allowance  has  been  made  for  the  over-estimate 
of  success  into  which  the  advocate  of  any  peculiar  mode  of  treat- 
ment is  almost  sure  to  fall,  these  results  still  remain  far  more 
favoral)le  than  have  been  obtained  by  any  other  mode  devised  for 
the  radical  cure  of  ovarian  dropsy. 

The  experience  of  others,  too,  confirms  in  a  great  measure 
Boinet's  statements,  for  M.  Cazeaux^  professes  to  have  had  48 
cures  out  of  62  injections  of  single  ovarian  cysts,  11  cases  in 
which  the  advance  of  disease  was  retarded,  and  only  3  deaths. 
M.  Velpeau,  too,  in  the  discussion  at  tlu3  Academy  of  Medicine 
in  Paris,  in  the  year  1856,^  estimated  the  operations  which  had 
been  made  down  to  that  time  at  130,  of  which  only  30  terminated 
fatally,  64  were  permanent  cures,  while  the  fluid  reaccumulated 
in  36.  In  20  of  the  30  fatal  cases,  however,  the  opening  into  the 
cyst  had  been  maintained  fistulous,  and  to  this  proceeding,  which 

1  Gazette  Hebdomadaire,  Nov.  21, 1856,  p.  828. 

2  In  one  of  these  cases,  though  the  tumor  was  punctured  four  times,  it  was  in- 
jected only  thrice,  and  in  another  only  twice. 

'  As  quoted  by  Schuh,  Bee  Canstatts  Jakresbericht  for  1859,  8vo,,  iv,  Wiirzhurg, 
1860,  p.  351.  *  Bulletin  de  I'Acad&mie  de  Medecine,  1856. 


BY    IODINE    INJECTIONS.  461 

he  cliaracterizes  as  bad  and  detestable,  M.  Velpeau  is  disposed  to 
attribute  the  patient's  death,  rather  than  to  the  mere  employment 
of  the  iodine  injections.  The  elaborate  work  of  Glinther,'  con- 
tains the  statistics  of  these  injections  down  to  the  year  IHoO,  and 
though  the  results  are  far  less  ftivorable  than  those  of  Boinet, 
Oazeaux,  or  of  Dr.  Simpson,  they  yet  are  in  the  main  very  en- 
couraging.    Out  of  158  cases,  there  were, 

82  recoveries. 
48  relapses. 

13  in  which  no  result  was  observed. 
59  deaths. 
6  results  not  stated. 

In  other  words,  of  the  cases  whose  results  were  known,  21  per 
cent,  had  a  favorable  issue,  38.8  terminated  in  the  patient's  death. 
These  figures  do  not  yield  data  such  as  to  enable  us  to  judge  of 
the  suitability  of  the  different  cases  for  the  injection ;  of  the  danger 
which  those  patients  ran  who  merely  survived,  or  those  who  were 
actually  cured,  nor  of  the  degree  to  which,  in  the  instances  where 
death  took  place,  the  fatal  event  was  directly  caused,  or  notably 
hastened,  by  the  injection.  These,  however,  are  the  very  points 
concerning  which  we  need  accurate  information  before  we  can  at 
all  justly  appreciate  the  indications,  or  contraindications,  for  this 
or  for  any  other  operation. 

Forty  or  fifty  cases  of  injection  of  iodine  into  ovarian  cysts, 
followed  by  only  one  death,  is  a  result  more  favorable  than  any 
one,  save  Dr.  Simpson,  has  ever  attained;  but,  at  the  same  time, 
the  dangers  of  the  proceeding  ap[K\ar  to  be  dependent,  to  a  con- 
siderable degree,  on  causes  within  the  control  of  the  operator. 
In  the  earlier  cases  the  use  of  the  injection  was  associated  with 
the  attempt  to  keep  the  cyst-wound  open,  and  this  proceeding  no 
doubt  had  a  considerable  share  in  bringing  about  the  fatal  issue. 
The  allowing  the  solution  to  remain  in  the  c^'st,  possibly  also  the 
em[)loyn)ent  of  too  strong  a  solution,  are  also  im[>ortant  elements 
to  be  taken  into  account  in  estimating  the  risks  of  iodine  injec- 
tions. M.  Boinet  was  accustomed  to  employ  a  mixture  of  equal 
parts  of  distilled  water,  and  the  tincture  of  iodine  of  the  Paris 
Pharmacopoeia,  which  contains  more  than  twice  as  much  iodine 
as  the  compound  tincture  of  the  London  Pliarniacopceia;  the  ])ro- 
portion  being  1  part  to  12^  in  the  former,  1  to  29  in  the  latter. 
From  .^iv  to  i^viii  or  fyx  of  this  mixture,  to  which  some  iodide  of 
potass  has  been  added  to  insure  the  complete  solution  of  the 
iodine,  are  thrown  into  the  cyst,  and  after  being  allowed  to  remain 
there  tor  from  seven  to  ten  minutes,  are  withdrawn  through  the 
caimla.  Although,  in  many  instances,  a  considerable  f[uantity  of 
the  tincture  of  iodine  has  remained  behind  in  the  cyst  without 
any  l)ad  symptoms  i-esulting,  M.  Boinet  always  ]»refers  allowing 
of  its  escape  after  the  lapse  of  some  minutes.     No  one  can  read 

'  Lehre  der  Bhdigen  Operationen,  folio,  38  Lieferung,  Leipzig,  1859,  p.  186. 


462  CURE     OF    OVARIAN    DROPSY 

the  particulars  of  M.  Teale's  cases,^  of  wliicli  one  proved  fatal, 
while  the  other  two  patients  remained  nnconseious  for  fifteen  and 
fourteen  hours  respectively,  without  feeling  that  the  hazard  is 
greatly  increased  by  allowing  the  fluid  to  remain.  The  same 
symptoms  of  most  formidable  depression  are  also  noticed  in  the 
report  of  a  case  under  the  care  of  Mr.  Brown  in  St.  Mary's  Hos- 
pital.^ That  gentleman  appears  usually  to  allow  the  solution  of 
iodine  to  ren<ain  in  the  cyst,  and  to  combat  the  formidable  symp- 
toms which  result  from  the  practice  by  the  liberal  administration 
of  wine  and  brandy.  Among  my  patients  at  St.  Bartholomew's 
Hospital,  m  whom  the  injection  has  never  been  allowed  to  remain 
more  than  ten  minutes  in  the  cyst,  serious  depression  only  once 
followed  its  employment;  and  I  very  much  doubt  the  propriety  of 
adding  to  the  patient's  risks  those  of  poisoning  by  iodine,  when 
there  seems  good  reason  for  the  belief  that  the  peculiar  curative 
influence  of  the  agent  is  exerted  even  after  a  very  short  contact 
witli  the  cyst-walls. 

The  nature  of  this  influence  is  still  but  little  understood.  It  is 
clear  that  cj'st  inflammation  is  not  a  necessary  condition  for  suc- 
cess; for  in  several  instances  where  no  reaccumulation  of  fluid 
has  taken  place  no  pain  has  followed  the  operation,  nor  any  con- 
stitutional disturbance,  but  the  cyst  once  emptied  has  not  refilled, 
and  recovery  has  not  been  purchased  by  the  suftering  or  the  peril 
which  seem  insepaiable  from  all  other  modes  of  cure  of  ovarian 
dropsy.  "We  have  at  jtresent  no  account  of  the  appearances  found 
on  dissection  after  the  successful  employment  of  this  proceeding 
in  ovarian  disease.  Observation,  however,  has  already  taught  us 
that  the  radical  cure  of  hydrocele  by  no  means  of  necessity  implies 
the  formation  of  adhesions  between  the  opposite  surfaces  of  the 
sac.  Such  adhesions,  too,  appear  to  occur  less  often  after  the  use 
of  iodine  injections  than  after  any  of  the  other  usual  surgical  pro- 
ceedings for  the  cure  of  hydrocele,'' and  if  the  0})po8itc  surfaces  of 
the  comparative!}'  small  cyst  in  that  case  fail  to  become  adherent, 
it  is  little  likely  that  union  should  take  place  between  the  sides  of 
a  large  sac  which  has  been  distended  by  man}'  quarts  of  fluid.  It 
is  possible  that  something  is  lost  of  that  securit}"  against  relapse, 
which  enhances  so  much  the  value  of  any  cure;  it  is  certain,  how- 
ever, that  much  is  gained  in  safety  if  we  can  avoid  the  risks  of  a 
disease  so  formidable,  so  difficult  to  control,  as  cyst-inflammation. 

Even  after  all  precautions  have  been  taken,  and  when  the  injec- 
tion is  employed  in  cases  apparently  best  suited  for  it,  unexpected 
death  sometimes  takes  |»lace,  as  in  instances  recorded  by  Lowen- 
hardt^  and  Legrand.^  Loweuhardt's  patient  died,  apparently  from 
mere  shock,  fourteen  hours  after  a  first  tapping  and  injection.    The 

^  Reported  by  Mr.  Hardwick  in  Medical  Times,  Jan.  31  and  Feb.  7,  18-57. 

2  Laiicet,  March  21,  1857,  p.  290 

3  See  the  observations  of  M.  Hiitin  on  the  cure  of  hydrocele,  quoted  by  M. 
Boinet,  op.  cit.,  p.  270. 

*  Monaischrift  fUr  Gehertskiinde,  vol.  xvi,  p.  241. 

6  Gazette  des  Hopiiaux,  July  9,  18(il,  p.  320,  and  Oct.  12,  1861,  p.  479. 


BY    IODINE    INJECTIONS.  463 

injection  was  accompanied  with  intense  pain,  and  followed  by 
great  depression,  but  no  trace  of  peritonitis  or  of  cjst-inflamma- 
tion  was  found  on  examining  the  body  after  death.  Both  of 
Legrand's  patients  died  of  peritonitis.  In  one,  tapping  and  the 
injection  of  iodine  had  been  resorted  to  six  months  before,  without 
the  slightest  symptom  of  local  discomfort  or  constitutioinil  dis- 
turbance. In  the  other,  tapping  with  iodine  injection  had  been 
resorted  to  nine  times;  on  the  last  occasion,  four  years  previously, 
the  disease  had  seemed  to  be  brought  to  a  standstill,  but,  after 
the  lapse  of  that  time,  a  fresh  puncture  and  injection  ])ecanie 
necessary.  On  its  repetition,  three  montlis  later,  or  in  other 
words,  on  occasion  of  the  eleventh  punctnre  and  injection,  violent 
peritonitic  symptoms  came  on,  under  which  tlie  patient  sank  in 
the  course  of  twenty-seven  hours. 

My  ow^n  experience,  which  extends  but  to  ten  cases,  is  too 
limited  to  be  of  much  value,  but  I  have  thrown  its  results  into  a 
tabular  form  for  convenience  of  reference. 

The  first  thing,  perhaps,  which  strikes  one  in  looking  over  the 
table,  is  the  fact  that  in  no  instance  did  the  injection'  have  a  fatal 
result,  except  in  that  case  in  which  it  escaped  into  the  abdominal 
cavity,  while  three  times  no  constitutional  disturbance  wdiatever 
was  produced  by  the  proceeding;  and,  further,  it  is  worth  notice 
that  no  connection  seemed  to  subsist  between  the  severity  of  the 
S3'mptoms  that  were  produced  in  some  cases,  and  the  permanent 
cure  of  the  patient.  This  uncertainty  with  reference  to  the  severity 
of  the  symptoms  following  the  injection,  has  also  been  remarked 
upon  by  Schuh,^  who  says,  that  "the  primary  efiects  of  iodine  in- 
jections are  very  variable,  and  cannot  at  all  be  estimated  before- 
hand. Even  in  the  same  patient  an  injection  will  sometimes  give 
rise  to  no  sign  of  either  local  or  constitutional  reaction,  while 
another  will  be  followed  by  a  storm  of  perilous  symptoms."  Cyst- 
inilanimation,  indeed,  appeared  to  be  excited  on  several  occasions, 
though  it  yielded  tolerably  readily  to  moderate  depletion.  Its 
signs  were  in  most  instances  partly  masked,  partly  exaggerated 
by  the  symptoms  of  iodism,  as  those  phenomena  have  been  termed 
which  are  produced  by  tlie  absorption  of  large  quantities  of  iodine 
into  the  blood.  Great  abdominal  pain,  usually,  however,  s})ecdily 
abating,  extreme  depression,  cold  extremities,  a  very  frecpient  and 
very  feeble  pulse,  which  sometimes  becomes  altogether  imper- 
ceptible at  the  wrist  for  a  few  hours,  a  sense  of  sickness,  often 
accompanied  by  actual  vomiting,  drowsiness  without  sleep,  thirst, 
and  a  metallic  taste  in  the  mouth,  are  the  symptoms  which  occa- 
sionally follow  immediately,  or  within  the  course  of  a  few  hours 

1  The  injection  which  I  have  been  accustomed  to  employ  is  a  solution  pre]wrod 
at  the  time,  as  recommended  by  M.  Guibourt  of  Paris  (see  Boinet,  up.  cit.,  p.  101), 
and  wliicii  consists  of  5  parts  oV  iodine,  ">  of  iodide  of  pofassa,  oO  of  spirit,  and  100 
of  water.  The  quantity  of  iodine  which  this  mixlurc  contains  does  not  differ 
materially  from  that  which  would  be  present  in  a  mixture  of  equal  parts  of  com- 
pound tincture  of  itidine  of  the  London  Pharmacopo'ia,  and  distilled  water. 

^  As  rejiorted  in  Canstatt's  Jahresbcric/ii,  vol.  iv,  AViirzburg,  18G1,  j).  401. 


464 


IODINE    INJECTIONS    IN    OVARIAN    DROPSY. 


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EESULTS    OF    IODINE    INJECTIONS    ESTIMATED,        465 

after  tlie  injection  of  the  cyst,  and  suggest  a  peril  even  more 
imminent  than  in  all  prohahility  really  attends  them.  Coupled 
with  this  condition,  which  usually  loses  its  more  formidahle  features 
in  the  course  of  twenty-four  hours,  there  is  a  very  scanty  secretion 
of  dark  claret-colored  urine,  loaded  with  iodine;  and  a  diminu- 
tion of  the  amount  of  iodine,  an  increase  in  the  quantity  of  urine, 
and  an  abatement  of  the  symptoms  take  place  simultaneously.  In 
the  case  where  the  symptoms  of  iodism  were  most  alarming,  an 
aqueous  solution  of  iodine  was  employed,  and  one  of  the  benefits 
of  the  admixture  of  a  certain  quantity  of  spirit  with  the  fluid 
appears  to  be  that  it  retards  the  absorption  of  the  iodine.  I  found 
traces  of  iodine,  however,  in  the  urine  fourteen  days  after  the  in- 
jection of  the  solution  that  I  usually  employed,  and  wliicli  con- 
tained a  third  part  of  spirit,  and  this  although  the  fluid  was 
allowed  to  remain  in  the  cyst  only  for  ten  minutes. 

The  observation  of  these  facts  rendered  me  very  decidedly  op- 
posed to  the  practice  either  of  employing  very  strong  solutions  of 
iodine,  or  of  allowing  the  injection  to  remain  permanently  in  the 
cyst, — a  practice  to  which  the  formidable  symptoms  and  the  fatal 
results  which  have  occui-red  in  some  English  cases  appear  to  me 
in  great  measure  attributable.  The  uncertainty  as  to  the  cases 
which  will  bear  the  iodine  injection  well,  as  distinguished  from 
those  in  which  cyst  inflammation  or  profound  iodism  will  be  ex- 
cited by  it,  is  a  drawback  irom  its  value  which  this  operation 
shares  with  every  other  proceeding  for  the  cure,  or  even  tor  the 
temporar}^  relief,  of  ovarian  dropsy. 

It  is  hard  to  say  how  long  a  lapse  of  time  is  necessary  to  estab- 
lish the  permanence  of  a  supposed  cure  of  this  disease.  At  the 
end  of  two  years  after  the  injection  of  a  cyst  with  the  solution  of 
iodine  no  re-collection  of  fluid  had  taken  place  in  one  case,  and 
it  is  perhaps  fair  to  regard  that  as  an  instance  of  its  cure.  In  two 
other  cases,  however,  the  obliteration  of  the  first  cyst  was  followed 
at  the  end  of  eighteen  months  in  the  one,  and  of  two  3'ears  in  the 
other,  by  the  development  of  others,  which  showed  that  the  tumor 
was  not  of  that  simple  kind  which  it  had  at  first  been  supposed 
to  be.  Such  occurrences  illustrate,  indeed,  the  incompleteness  of 
the  success  obtained  b}^  this  proceeding  as  com})ared  with  the  really 
radical  cure  cflected  by  the  extirpation  of  the  ovary.  But,  on  the 
other  hand,  even  they  are  not  without  an  encouraging  feature,  since 
they  show  that  the  presence  of  solid  matter  in  the  tumor  does  not 
contraindicate  the  injection,  nor  the  compound  character  of  the 
cyst  always  render  the  operation  dangerous,  but  that  from  it  we 
may  expect  retardation  of  the  disease  in  cases  where  yet  we  must 
abandon  tlie  hope  of  effecting  a  permanent  cure. 

The  real  value  of  this  proceeding  still  remains  to  be  definitely 
determined  by  larger  trials  than  have  yet  been  made,  and  it  seems 
almost  idle  to  bring  forward  an  array  of  names  to  settle  a  question 
which  as  yet  is  not  ripe  for  a  decision.  In  this  country,  Dr.  Simp- 
son is  the  only  person  who  has  often  had  recourse  to  iodine  injec- 

30 


466  VALUE    OF    IODINE    INJECTIONS 

tions  in  ovarian  dropsy,  and  I  Lave  already  mentioned  the  ex- 
tremely favorable  conclusions  at  which  he  has  arrived. 

The  cessation  of  my  connection  with  an  hospital  has  deprived 
me  of  the  opportunity  of  carrying  my  personal  investigations  any 
further;  and  it  is,  I  think,  to  be  regretted  that  attention  has  during 
the  past  few  years  been  so  exclusively  turned  in  this  country  to 
the  question  of  ovariotomy  that  no  attempts  have  been  made  to 
determine  more  accurately  the  indication  for  the  use  of  these  in- 
jections, and  the  means  by  which  their  danger  may  be  lessened. 
In  France  and  Germany,  too,  though  still  resorted  to,  their  value 
has  not  been  subjected  to  that  searcliing  examination  which  could 
alone  test  their  real  Worth,  and  disappointment  at  finding  the  early 
estimates  of  success  exaggerated  seems  likely  to  lead  to  a  measure 
of  undeserved  neglect. 

Professor  Scanzoni,  however,  while  still  keenly  alive  to  the  risks 
which  he  dwelt  on  in  the  former  edition  of  his  book,*  published 
eight  j^ears  ago,  has  given  the  operation  a  renewed  trial ;  and  all  the 
three  cases  in  which  he  has  employed  it  have  had  a  good  result.  He 
has  taken  the  following  precautions,  to  which  some  of  the  success 
is  doubtless  due.  The  cyst  was  first  emptied  as  completely  as  pos- 
sible, and  then,  before  the  injection  was  employed,  a  most  careful 
examination  was  made  to  determine  whether  the  cyst  was  a  simple 
one,  and  if  it  appeared  not  to  be,  the  injection  was  not  employed. 
If  it  were  proceeded  with,  an  elastic  catheter,  exactly  fitting  the 
canula,  was  carried  down  to  the  bottom  of  the  cyst,  and  from  one 
ounce  to  three  of  pure  tincture  of  iodine  were  injected  through  it. 
In  the  course  of  a  few  n)inutes  the  whole  of  the  fluid  was  care- 
fully withdrawn  by  means  of  a  syringe,  and  after  the  closure  of 
the  wound  the  abdomen  was  kept  covered  with  cloths  wrung  out 
of  iced  water  so  long  as  the  pain  produced  by  the  injection,  and 
which  usually  was  severe,  continued.  In  the  first  of  his  three 
patients  the  cyst  refilled  in  six  weeks  after  the  first  injection.  Its 
repetition  at  the  end  of  that  time  was  followed  by  extensive  peri- 
tonitis, from  which  the  patient  recovered,  and  continued  quite  well 
at  the  end  of  a  year.  In  the  second  case  a  single  puncture  and  in- 
jection were  followed  by  a  cure  which  was  substantiated  at  the 
end  of  ten  months.  In  the  tliird  case  two  tumors  existed,  pos- 
sibly aflecting  both  ovaries.  In  the  one  which  was  injected,  no 
re-collection  of  fluid  had  taken  place  at  the  end  of  four  months ; 
but  the  other  tumor,  which  had  at  first  seemed  solid,  was  becom- 
ing softer,  and  it  appeared  probable  that  it  would  before  long  be 
in  a  state  to  admit  of  tapping  and  injection. 

We  need,  for  the  just  estimate  of  the  value  of  iodine  injections, 
an  answer  to  the  following  questions.  I  commend  them  especially 
to  those  gentlemen  who  seem  to  consider  that  a  clamorous  denun- 
ciation of  ovariotomy,  unaccompanied  by  any  effort  to  increase  our 
knowledge  of  the  pathology  of  ovarian  diseases,  or  to  add  to  our 

1  Op.  cit,  3d  ed.,  1864,  p.  468. 


ESTIMATED.  467 

therapeutical  resources,  befits  the  solemn    engagements   under 
which  we  stand  to  our  own  profession  and  to  our  fellow-creatures. 

It  needs  to  be  ascertained — 

1st.  How  far  these  injections  may  be  safely  employed  in  cases 
of  compound  cysts,  and  what  etfect  they  have  in  retarding  the 
deveh:)pnient  of  the  principal  cyst?  and  whether  the  cliaracter  of 
the  fluid,  as,  for  instance,  its  being  pellucid,  and  but  slightly 
viscid,  indicates  the  use  of  the  injection  even  in  cases  of  multi- 
locular  cysts? 

2d.  How  far  the  caution  suggested  by  Professor  Simpson,  of 
never  employing  the  injection  after  a  first  tapping,  diminishes  its 
risk  ? 

3d.  "Whether  a  watery  solution  of  iodine,  or  one  containing 
spirit,  is  the  safer,  and  whether  the  employment  of  a  large  quan- 
tity of  a  weak  solution,  or  of  a  small  quantity  of  a  strong  solution, 
is  attended  by  the  greater  hazard  ? 

4th.  What  means  afford  the  best  guarantee  against  the  escape 
of  the  injection  into  the  abdominal  cavity? 

5tli.  How  long  it  is  expedient  to  allovv^  the  injection  to  remain 
in  the  cyst,  and  whether  its  complete  removal  by  an  exhausting 
syringe  on  the  principle  of  Bowditch's  furnishes  an  important 
safeguard  against  the  occurrence  of  iodism,  cyst-inflammation, 
or  peritonitis? 

6th.  What  relation  subsists  between  the  amount  of  pain  at  the 
time  of  the  injection  and  the  occurrence  of  dangerous  peritonitis 
or  cyst-inflammation  afterwards ;  and  consequently  how  far  is 
pain  to  be  taken  as  an  indication  for  desisting  from  the  injection  ? 

7th.  What  are  the  best  means  of  preventing  or  controlling  dan- 
gerous symptoms  after  the  injection  ? 

8th.  In  the  event  of  the  failure  of  a  first  injection,  what  is  to  be 
expected  from  its  repetition  ;  and  if  repeated,  is  it  desirable  that 
the  next  tapping  should  be  hastened,  or  that  interference  should 
be  postponed  until  the  patient's  general  condition  indicates  its 
necessity  ? 

The  grand  objection  to  most  proceedings  hitherto  devised  for 
cure  of  ovarian  dropsy  is  not  only  that  they  often  fail  to  accom- 
plish that  object,  but  still  more  that  they  frequently  destroy  the 
patient  who  submits  to  them.  A  comparatively  low  average  of 
successes  may  be  more  than  counterbalanced  by  an  equally  low 
rate  of  mortality;  but  a  very  high  probability  of  perfect  cure  is 
needed  to  outweigh  a  great  risk  of  life.  It  will,  I  apprehend,  be 
found  that  the  comparative  safety  of  the  iodine  injection  will  be 
its  great  recommendation.  For  my  own  part,  I  c<uifess  that  I 
shrink  from  playing  a  game  with  heavy  odds  against  success 
when  human  life  is  the  stake. 

How  tar  this  objection  applies  to  the  last  great  remedy,  the  re- 
moval of  the  diseased  organ,  must  be  the  subject  of  inquiry  at  the 
next  lecture. 


468  OVARIOTOMY: 

LECTURE    XXX. 

OVAKIAN  TUMORS  AND  DROPSY. 

Treatment,  continued.  Extirpation  of  the  diseased  otaries.  History  of 
the  operation,  its  two  varieties,  tiio  major  and  the  minor.  General  results  of 
the  operation  ;  its  mortality  ;  date  and  cause  of  death. 

Circumstances  modifying  its  hazards ; — existence  of  adhesions,  age  of  patient,  ex- 
tent of  incision,  character  of  tumor. 

Unfavorable  opinion  formerly  pronounced,  and  why;  its  results  and  those  of 
Csesarean  section  compared,  but  oj)ei-ation  to  be  judged  by  its  own  merits,  not 
by  comparison  witli  operations  for  other  purposes.  Reasons  assigned  for  re- 
considering that  opinion.  Attempt  to  estimate  conditions  in  which  ovariotomy 
is  justifiable. 

It  still  remains  for  us,  last  of  all,  to  examine  the  great  radical 
cure  of  ovarian  drojjsy,  the  extirpation  of  the  diseased  organ. 

I  liavefelt  mnch  at  a  loss,  now  that  I  am  called  on  to  reconsider 
the  opinions  which,  not  witliout  much  careful  thought,  I  arrived 
at  and  ventured  to  express  seven  years  ago,  as  to  the  way  in  which 
I  can  m'ost  fairly  state  the  changes  that  these  opinions  have  under- 
gone. I  believe  that,  on  the  whole,  it  will  be  the  better  plan  to 
retain  my  former  statements  and  the  grounds  on  which  my  con- 
clusions were  based  entirely  unchanged,  and  afterwards  to  try  to 
indicate  how  and  why  1  have  now  arrived  at  different  conclusions. 
T  do  this  because  I  think  that  my  former  opinions  coincided  very 
nearly  with  those  which  are  still  entertained  by  many  men  for 
whom  I  feel  very  high  respect,  and  from  whom  I  cannot  differ 
without  a  sense  of  misgiving  lest,  after  all,  I  should  be  mistaken. 

The  history  of  the  o])eration  has  been  so  often  related,  that  I 
need  not  occupy  much  time  in  repeating  its  details.  Performed 
for  the  first  time  in  the  year  1809  by  Dr.  ^lacdowell,  of  Kentucky, 
and  repeated  by  him  five  times  in  the  subsequent  ten  years,  it  yet 
did  not  attract  much  attention  nor  find  many  imitators,  even 
among  his  countrymen,  for  nearly  five-and  twenty  years.  Neither 
on  the  continent  nor  in  this  country  were  the  results  of  the  few 
instances  of  its  performance  at  all  encouraging;  and  down  to  the 
year  1840  it  had  been  attempted  in  its  original  form,  which  con- 
sisted in  the  making  a  long  incision  from  the  sternum  to  the  sym- 
physis pubis,  only  twenty-five  tinies.^     In  14  of  these  cases,^  the 

'  The  diligence  of  M.  Fock,  loc.  cit.,  p.  367,  has  discovered  the  mention  of  a  case 
where,  more  than  150  years  ago,  the  cyst  was  drawn  through  the  wound  made  in 
tapping,  by  a  sort  of  unintentional  anticipation  of  Mr.  Jcjatt'rcson's  operation  ;  and 
he  refers  also  to  a  similar  occurrence  having  ha]ippned  to  the  late  Mr.  Howship. 
These,  however,  are  not  instances  of  the  intentional  extirjjation  of  the  diseased 
ovarium,  and  cannot  be  taken  into  our  consideration  here,  any  more  than 
L'Auraonier's  case  (Memoires  de  la  Societe  Roynle  de  Medeclne,  1782,  4to.,  p.  296),  in 
which,  with  a  barbarous  surgery,  he  removed  the  ovary  distended  with  pus  in  con- 
sequence of  inflammation  after  deliverJ^ 

2  A  notice  of  these  earlier  cases  of  the  operation  by  the  large  incision  will  be 
found  in  the  Brilin/i  and  Foreig^i  Medical  Revieiv,  Oct..  1843;  and  three  cases  not 
noticed  there  are  referred  to  in  the  Report  on  Midwifery,  &c.,  for  1842-3,  published 
in  the  same  journal  for  April,  1844. 


ITS    MORTALITY.  469 

ovary  was  removed,  9  patients  survived  the  operation,  5  sank 
under  its  effects;  in  11  either  no  tumor  was  discovered,  or  adhe- 
sions prevented  its  removal ;  and  of  these  patients,  8  survived  the 
exposure  of  the  ahdominal  cavity,  3  were  destroyed.  Matters 
stood  thus  when  Mr.  Chiy  and  ^Ir.  AValne,  hy  the  pul)lication  of 
several  cases,  a  good  proportion  of  which  had  had  a  favorahle 
issue,  excited  the  attention  of  the  profession  to  the  suhject;  and 
though  it  was  some  time  before  the  operation  was  generally  re- 
garded as  a  legitimate  proceeding,  and  though  it  is  still  denounced 
by  some  surgeons  in  unmeasured  terms,  we  yet  can  reckon  now 
some  200  cases  in  which  it  has  been  resorted  to,  and  are  therefore 
in  a  position  to  form  some  opinion  of  its  advantages  and  its  dan- 
gers. The  operations,  indeed,  have  not  all  exactly  resembled 
those  first  performed,  for  in  the  year  1838,  Mr.  Jeaffreson,  of 
Framlingham,  in  Suffolk,  endeavored  to  lessen  tlie  formidable 
cliaracter  of  tlie  proceeding  by  tapping  the  cyst,  and  then  with- 
drawing it  through  as  small  an  opoiing  as  possible.  This 
has  been  called  the  operation  by  the  small  incision,  in  contradis- 
tinction to  the  other,  or  operation  by  the  large  incision.  The 
advocates  of  each  of  these  proceedings  are  very  strenuous  in  in- 
sisting upon  the  merits  of  that  of  which  they  approve,  and,  as  we 
shall  presently  see,  each  has  its  peculiar  advantages.  In  many 
respects,  however,  they  stand  upon  common  ground,  and  we  may 
class  them  together  for  the  present  while  we  seek  to  ascertain 
what  rate  of  mortality  is  to  be  apprehended,  and  what  measure 
of  success  may  be  hoped  for  from  the  attempt  to  extirpate  the 
dropsical  ovary. 

Several  writers  have  collected,  with  much  diligence,  the  statistics 
of  this  operation,  of  which  there  are  now  more  than  200  instances 
on  record.  This  last  is  the  number  arrived  at  by  Fock,  in  his  very 
valuable  paper  on  the  subject;'  and  though  the  past  eighteen 
months  have  furnished  a  few  additional  cases  both  of  success  and 

1  The  first  of  these  tables,  and  the  foundation  of  all  subsequent  ones,  was  pub- 
lished by  Dr.  W.  T.  Atlee  in  the  Amf.rlcan  Jouninl  for  April,  184">,  and  was  coiiicd, 
without  quite  adequate  aeknowledijjment,  by  Mr.  S.  Lee,  in  his  very  useful  work 
on  uterine  tumors.  Had  he  lived,  the  omission  would  have  been  reetilied,  but 
justice  to  Dr.  Atlee  compels  me  to  refer  to  it  iiere.  Dr.  Robert  Lee  lias  eoileeted  in 
his  Clinical  lieporis,  &e.,  the  particulars  of  102  cases  in  which  ovariotomy  was 
either  attempted  or  actually  ]ierformed  in  this  country;  while  Kiwi-ch's  taiile,  in 
vol.  ii,  of  h\^  Klini.ic/ie  Fo/"i!/'a<7^,  supplies  some  additional  cases,  chiefly  contributed 
by  continental  ])ractitioners.  In  the  American  Journal  for  April,  IS'iO,  Dr.  Atlee 
gives  the  general  results  of  179  cases,  though  not  with  the  same  detailed  refiT- 
ences  as  in  his  former  table;  and  in  the  same  journal  for  April.  18')'),  he  contrib- 
utes a  synopsis  of  30  cases  of  ovariotomy  occurring  in  his  own  jirai'tice.  Mr.  Clay, 
of  Manchester,  who  has  performed  the  ojieratinn  miir(>  fri'cpiently  tlian  any  nther 
person,  ])ublished  in  tiie  BrUish  Record  af  Qhs/rlric  Mrdirinr  the  particulars  of  40 
cases  that  came  under  his  own  care,  and  his  papers  on  this  subject  were  collected 
and  published  by  liim  at  Manchester  in  1818.  In  Marib,  18')t>  he  .sent  ii  letter  to 
Dr.  Simpson,  which  appeared  in  Ed.  Med.  Journal  for  that  month,  in  which  ho 
briefly  states  the  results  of  29  additiomil  cases.  From  all  these  sources,  as  well  as 
from  others  either  overlooked  by  former  writers,  or  which  have  occurred  subse- 
(piently  to  their  investigations.  Dr.  Fock  has  collected  a  total  of  l21»'J  ca.ses,  on  which 
he  bases  his  conclusions,  and  I  have  availed  myself  of  his  labors. 


470  PERFORMANCE    OF    OVARIOTOMY 

of  failure,  it  is  yet  so  convenient  to  deal  with  round  numbers  that 
I  prefer  adopting  his  figures  as  they  stand.  Now  these  200  cases 
of  actual  extirpation  of  the  ovary  yield  111  recoveries  to  89  deaths; 
or,  in  other  words,  the  mortality  is  44i  per  cent.,  or  not  very  far 
short  of  half  the  number  of  persons  in  whom  the  operation  is 
completed  die  from  its  eflects.  But,  besides  these,  there  are  92 
cases  in  which  the  operation  could  not  be  completed  on  account 
of  the  presence  of  adhesions,  or  of  the  tumor  having  some  other 
situation  or  other  attachments  than  was  supposed  beforehand,  or 
in  which  some  even  greater  diagnostic  error  was  committed,  and 
the  very  existence  of  the  tumor  was  found  to  be  a  mistake.  Of 
these  92  patients,  31  died,  or  33.6  per  cent.,  or  1  in  every  3;  but 
9  of  those  who  survived  after  passing  through  great  perils,  are  re- 
ported to  have  been  more  or  less  completely  cured  of  the  disease. 
Putting  all  the  cases  together,  it  seems  that  of  292  recorded  in- 
stances of  the  operation  being  attempted,  120  ended  in  death,  and 
92  in  failure;  or,  in  other  words,  the  chances  are  two  to  one  that 
the  operation  will  be  accomplished  ;  but,  if  it  succeeds,  they  are 
nearly  equal  that  the  patient  will  die,  and,  if  it  fails,  the  prospect 
of  her  surviving  the  fruitless  interference  is  only  double  that  of  her 
sinking  in  consequence  of  it. 

The  belief  was  expressed  by  the  advocates  of  the  operation  that 
the  mortality  attendant  on  its  pertbi'mance  was  in  course  of  dimi- 
nution, and  that  with  the  perfecting  of  our  diagnostic  skill  the 
proportion  of  unfinished  operations  was  also  lessening.  "  The  rate 
of  mortality,"  says  Dr.  Atlee,  in  the  year  1850,  "has  very  much 
diminished  since  the  publication  of  my  table  in  1845.  Then  there 
was  1  death  in  every  2*|  cases  of  gastrotomy,  or  37.62  deaths  in 
every  100  cases.  Since  the  publication  of  that  table  78  cases  have 
occuired,  in  which  there  was  1  death  in  every  3|  cases,  or  26.92 
deaths  in  every  100  cases.  There  has  also  been  a  diminution  in 
the  proportion  of  unfinished  operations  ....  hence  diagnosishas 
also  improved."'  Unfortunately,  as  we  have  seen,  it  needs  but  to 
increase  the  number  of  observations  in  order  to  do  away  with  the 
correctness  of  this  very  natural,  though  too  sanguine  expectation. 
One  death  in  every  2||  of  those  cases  in  which  the  operation  was 
completed,  or  1  in  Sj\  of  all  cases,  those  included  in  which  the 
operation  was  abandoned,  such  are  the  results  of  the  most  recent 
data;  while  the  number  of  instances  in  which  the  ovary  could  not 
be  extirpated  has  risen  from  1  in  5/4,  at  which  Dr.  Atlee  estimated 
it  in  1850,  to  1  in  S^^  six  years  atterwards,  according  to  the  cal- 
culation of  Dr.  Fock.  This  last  category  of  cases,  too,  would,  1 
doubt  not,  be  swelled  far  beyond  its  present  dimensions,  if  every 
instance  in  which  an  exploratory  incision  sufficed  but  to  discover 
the  impossibility  of  any  further  proceeding,  were  placed  upon 
record.  Besides  the  cases  88,  101,  and  103,  in  Dr.  Lee's  list,  the 
first  of  which  occurred  during  my  connection  with  the  Middlesex 

1  American  Journal,  April,  1850. 


OFTEN    IMPRACTICABLE.  471 

ITospital,  while  the  other  two  were  patients  of  my  own,  T  have 
had  two  other  cases  at  St.  Bartholomew's  Hospital,  in  wliich  the 
attempt  was  made,  with  m_y  full  concurrence,  to  remove  the  ovary, 
but  was  made  unsuccessfully.  One  of  the  patients,  a  cirl  of 
twenty-two,  survived  the  operation  four  months,  hut  after  having 
struggled  through  an  attack  of  cyst-inflammation,  that  followed 
within  thirty-six  hours  after  it  was  attempted,  she  sank  into  a 
state  of  hectic,  which,  after  death,  seemed  to  be  accounted  for  by 
the  extension  of  the  inflammation  to  another  cyst  that  was  found 
distended  by  more  than  a  quart  of  pus.  The  other  case  was  that 
of  a  married  woman,  forty-seven  years  old,  in  whom  the  disease 
had  been  of  very  rapid  development,  but  the  cyst  was  ap])arcntly 
single,  while  the  absence  of  any  history  of  peritonitis,  and  tlic 
extreme  mobility  of  the  tumor,  seemed  to  warrant  the  tolerably 
confident  expectation  that  no  important  adhesions  existed  to  inter- 
fere with  its  removal.  This  hope  was  found,  however,  to  be  illu- 
sory, and  death  took  place  from  cyst-inflammation  with  all  the 
symptoms  of  pyoemia  seventeen  days  after  the  operation.  The 
examination  after  death  illustrated  a  source  of  difliculty  which  no 
wisdom  could  have  foreseen.  There  were,  indeed,  adhesions  to 
the  abdominal  peritoneum,  and  these  it  may  be  conceded  (though 
I  am  by  no  means  convinced  of  the  fact)  that  the  well-skilled  tact 
of  some  one  else  might  have  detected.  But  the  upper  and  pos- 
terior wall  of  the  cyst  adhered  to  the  intestines,  while  from  its 
upper  part  tliere  passed  off  a  pyriform  prolongation,  which  reached 
up  as  high  as  the  eighth  rib,  and,  dividing  into  three  separate 
branches  or  diverticula,  adhered  to  the  intestines,  to  tlie  pancreas, 
and  to  the  capsule  of  the  left  kidney.  It  happens,  then,  that  my 
personal  experience  of  ovariotomy  is  made  up  of  the  observation 
of  five  cases,  in  everyone  of  which  the  operation  was  undertaken, 
after  much  consideration,  with  the  approval  and  under  the  direc- 
tion of  surgeons  of  large  experience  and  undoubted  skill,  but  who, 
in  every  instance,  were  baffled  in  their  attempt.  Two  of  these 
cases  are  now  published  for  the  first  time,  and  go  to  swell  the  list 
of  unsuccessful  operations.  They  were  not  withheld  before  excej)t 
as  the  mention  of  many  an  unsuccessful  operation  is  withheld, 
because  it  teaches  no  new  lact,  and  serves  only  to  illustrate  some 
well-known  danger.  I  have  no  doubt,  however,  but  that  very 
many  other  cases  of  the  same  kind  must  have  occurred,  which  are 
still  unpublished  just  as  mine  were;  but  which,  could  they  be 
collected,  would  bring  out  the  dark  side  of  the  operation,  not  so 
much  perhaps  in  proving  the  mortality  from  completed  ovariotomy 
to  be  so  much  greater  \han  the  present  estimates,  as  in  shov^'ing 
foilures  to  accomplish  it  to  be  much  more  common,  and  those 
failures  to  be  much  oftener  attended  by  danger  and  followi'd  by 
death. 

Some  details  as  to  the  circumstances  in  which  death  takes  place 
from  this  operation,  and  the  conditions  which  favor  its  occurrence, 
may  help  us  to  a  more  correct  estimate  of  its  value. 


472  CAUSES    OF    MORTALITY 

In  68  cases  tlie  date  at  wliicli  death  occurred  is  mentioned. 

It  was  immediate,  or  within  six  hours,  in     4 

"  soon, "1 

"  on  the    1st  daj-, "6 

"  "         2d     "  "   14 

<<  "         3d     "  "   12 

"  "         4th  "  "4 

"  «'         5th  "  "6 

"  "         6th  "  "6 

"  "         7th  "  "1 

"  "  10th  "  "2 

"  "  11th  "  "1 

"  «'  12th  "  "2 

"  "  17th  "  "1 

"  "  21st   "  "2 

II  <(  22d     "  "1 

«  "  26th  "  "1 

"  "  30th  "  "1 

"  "  34th  "  "1 

"  "  70th  "  "1 

and  4  months  in  1. 

In  37  of  the  fatal  cases,  then,  or  in  more  than  half  the  number 
of  instances  in  which  death  takes  place,  it  occurs  within  seventy- 
two  hours  after  the  operation.  In  death  from  the  Ci^sarean  section 
61.2  per  cent,  of  the  fatal  cases  occur  within  the  first  seventy-two 
hours. ^  That,  however,  is  a  desperate  remedy  for  an  urgent 
danger,  and  if  life  is  cut  short  suddenly  by  its  failure,  nature  un- 
■aided  would  not  have  prolonged  it  further.  But  in  ovariotomy 
while  death  comes,  too,  in  53.6  per  cent,  of  the  fatal  cases  within 
sevent3'-two  hours  from  the  performance  of  the  operation,  there  is 
commonly  the  painful  reflection  that,  but  for  it,  life  would  have 
lasted  for  weeks  or  months ;  and  the  risk  of  such  a  result  will 
always  be  one  of  the  great  objections  to  the  operation,  and  one 
which  even  a  far  larger  proportion  of  successes  than  have  hitherto 
been  obtained  will  not  remove,  will  even  scarcely  lessen. 

In.  59  cases  the  cause  of  death  is  clearly  stated : 

In  29  cases  death  took  place  from  peritonitis. 

"  13  "  "  hemorrhage. 

"8  "  "  exhaustion. 

"     2  "  "  shock. 

"     8  "  "  suppuration,  or  abscess. 

"     2  "  "  ulceration  of  the  intestines. 

"     1  "  "  tetanus. 

"     1  "  "  phlebitis. 

59 

The  great  danger  here  seems  to  be  the  same  as  we  encounter 
in  the  performance  of  the  Csesarcan  section,  and  we  meet  with  it 
near]}'  as  often.  Inflammation  carries  off  51  per  cent,  of  those  who 
die  from  the  Csesareau  section,  49  per  cent,  of  those  to  whom  the 
operation  of  ovariotomy  proves  fatal.     The  risk  of  fatal  hemor- 

1  See  a  paper  by  the  author  on  the  Csesarean  section,  in  vol.  xxxiv  of  Med.  Chi?'. 
Tra7isactions,  p.  61. 


OF    OVARIOTOMY.  473 

rLage  appears  to  be  miicli  greater  in  the  latter  than  in  the  former 
case,  13  out  of  59  having  died  from  it  after  extirpation  of  the 
ovary;  only  14  out  of  147  from  hemorrhage  alone  after  the  C?esa- 
rean  section.  Shock,  however,  which  forms  a  very  injportant 
element  among  the  various  dangers  which  attend  the  latter  op- 
eration, has  scarcely  any  share  in  the  production  of  death  from 
ovariotomy,  though  the  somewhat  vague  term  exhaustion  prob- 
ably includes  some  instances  in  which  death  took  place  from  tlie 
direct  result  of  shock  to  the  nervous  system.  It  is  likely  that 
care  and  improvements  in  surgery  may  somewhat  lessen  the  dan- 
gers of  hemorrhage,  but  the  great  frequency  of  inHammation,  both 
after  this  operation  as  well  as  after  the  Cresarean  section,  certainly 
makes  it  questionable  whether  the  laying  open  the  abdominal 
cavity  can  be  looked  on  as  so  innocent  a  proceeding  as  some 
writers  believe  when  they  speak  of  exploratory  incisions  as  all 
but  devoid  of  hazard. 

The  presence  or  absence  of  adhesions,  the  size  of  the  incision, 
the  state  of  the  patient,  and  the  character  of  tlie  tumor,  have  all 
been  referred  to  as  modilying  the  dangers  of  the  operation,  and 
consequently  as  deserving  of  consideration  in  the  selection  of  cases 
for  which  it  is  suitable.* 

In  91  cases  adhesions  more  or  less  considerable  existed ;  in  54 
there  were  none.  Of  the  former,  44,  or  48.3  per  cent,  died;  17, 
or  31.2  per  cent,  of  the  latter.  1  cannot  state  the  exact  number 
of  instances  in  which  out  of  these  91  cases  the  operation  was  left 
unfinished  on  account  of  adhesions.  Anotherseries  of  facts, how- 
ever, will  serve  to  illustrate  this  point.  The  tables  of  Dr.  R.  Lee, 
and  of  M.  Fock,  contain  mention  of  92  uncompleted  operations; 
in  71  of  these  92  cases  the  adhesions  of  the  tumor  were  the  only 
reasons  for  the  tliscontinuance  of  the  attempts  at  its  extir[iation. 
In  many  of  these  cases  the  wound  was  at  once  closed  alter  the 
evacuation  of  the  contents  of  the  cyst,  and  with  the  infliction  of 
the  least  possible  amount  of  violence  upon  it;  but  nevertheless, 
more  than  a  third  of  these  patients,  or  35.2  per  cent.  died.  The 
diagnostic  difhculty  does  not  seem  as  yet  to  have  been  diminished 
by  all  the  attention  which  has  been  bestowed  upon  it,  and  the 
well-skilled  tact  of  those  who  have  oftenest  performed  ovariotomy 
appears  in  this  respect  to  give  to  its  possessor  but  little  sui>eriority 
over  the  novice.  AH  the  measures  which  have  been  proi>osed  for 
ascertaining  the  freedom  of  an  ovarian  tumor  from  adhesions 
afi:brd  little  if  any  information,  exce})t  as  far  as  the  relation  of  the 
cyst  to  the  abdominal  parietes  is  concerned.  The  adhesions  to 
the  abdominal  peritoneum,  however,  are  by  no  means  the  most 
important,  and  their  division  is  often  attended  with  but  little 
difficulty  or  danger,  while  connections  between  the  cyst  and  the 
various  viscera  are  frequently  altogether  undiscoverable  before- 
hand, and  attempts  at  dividing  them  are  always  hazardous,  very 

1  Somo  oftho.ee  niimbors  nro  taken  from  Dr.  Atloo'.^  pnpor,  in  Amrrirnn  Jniirrwl, 
April,  1850,  with  the  addition  of  all  cases  that  have  been  recorded  subsequently. 


474  CAUSES    OF    MORTALITY 

often  impracticable.  To  the  best  of  my  knowledge  there  is  no 
other  operation  in  surgery  concerning  which  the  chances  are 
nearly  one  in  three  that  some  unforeseen  difficulty  will  prevent  ita 
completion,  or  that  a  third  of  the  abortive  attempts  at  its  per- 
formance will  end  in  the  patient's  death. 

It  has  been  suggested  that  the  results  of  ovariotomy  are  partly 
governed  by  the  age  of  the  patient,  and  the  activity  of  the  sexual 
powers,  its  dangers  lessening  with  advancing  years.  In  the  Bul- 
letin de  la  Societe  de  Chirurgie^  is  a  table  constructed  from  data 
furnished  by  Dr.  Lee's  paper  on  ovarian  disease,  and  which  seems 
to  support  this  opinion.     It  is  as  follows : 


From  18  to  30  vears, 

40  operations, 

19  deaths. 

"       30  "  40'  " 

41 

13       " 

"       40  "  50     " 

17          " 

4       " 

"       50  "  60     " 

13          " 

2       " 

111  38 

A  few  facts  more,  however,  refute  these  conclusions  and  suggest 
others,  which  in  their  turn  further  observation  may  prove  errone- 
ous. I  have  obtained  from  other  sources  91  more  cases,  with  a 
total  of  41  more  deaths,  and  these  added  to  the  other  numbers 
yield — 

From  18  to  30  years,  69  operations,  31  deaths,  mortality  44.9  per  cent. 

"      30  "  40      "  69  "  22      "  "  Si. 8       " 

"      40  "  50     "  37  "  10      "  "  43.2        " 

"      50  <'  60     "  23  "  9      "  "  39.1        " 

"      60  "  68      '<  4  (<  1      .(  K  25.0       " 

202  79 

One  fact,  indeed,  which  the  other  table  indicates  this  also  cor- 
roborates, namely,  the  special  risk  attendant  upQn  the  operation 
in  very  young  women.  Time  will  show  the  value  of  iodine  injec- 
tions; should  they  prove  to  be  as  safe  and  as  successful  as  their 
advocates  believe,  it  is  very  satisfactory  to  know  that  precisely  in 
these  very  patients  are  simple  cysts  most  frequent,  and  conse- 
quently iodine  injections  are  most  applicable. 

It  has  been  alleged  that  the  success  or  fiiilure  of  the  operation 
has  depended  to  a  considerable  extent  on  the  size  of  the  incision 
made  into  the  peritoneum,  and  that  while  to  open  the  abdomen 
from  the  ensiform  cartilage  to  the  pubis  is  a  very  dangerous  pro- 
ceeding, the  withdrawal  of  the  punctured  cyst  through  a  small 
incision  is  attended  by  so  much  less  hazard  as  to  render  it  unfair 
to  place  the  two  operations  in  the  same  category.  This  difference 
between  the  two  operations  appears,  indeed,  to  be  very  clearly 
marked  in  the  statements  of  tliose  who  first  directed  attention  to 
this  subject.  The  late  Mr.  S.  Lee,  states'^  "that  in  85  cases  where 
the  major  operation  was  performed,  50  were  cured,  35  died,  making 
the  mortality  1  to  2| ;  in  23,  where  the  minor  operation  was  per- 
formed, 19  were  cured  and  4  died,  making  the  mortality  1  in  6." 

1  Bulletin  de  la  Societe  de  Chirurgie,  vol.  iii,  p.  42.  ^  Qp^  cii.,  p.  211. 


OF    OVARIOTOMY.  475 

The  result  of  further  observation  has  been  to  reduce  the  dis- 
crepancy between  the  two  operations  within  narrower  and  nar- 
rower limits;  not  by  proving  the  major  operation  to  be  less 
hazardous  than  was  su})posed,  but  by  showing  that  the  dangers  of 
the  minor  operation  had  been  underrated.  Some  tliree  years  and 
a  half  later  Dr.  Atlee'  having  collected  133  cases  of  the  major  and 
28  of  the  minor  operation,  found  the  mortality  from  the  former  to 
be  46,  or  1  in  2^^  ;  from  the  latter  8,  or  1  in  3 J.  I  have  since  col- 
lected 18  cases  of  the  major,  23  of  the  minor  operation,  referring 
to  the  latter  all  cases  in  which  the  incision  did  not  exceed  six 
inches  in  length,  making  the  total  151  of  the  former,  and  51  of 
the  latter,  from  which  the  respective  deaths  have  been  59  and  20, 
or  one  in  2|§,  and  1  in  2^  J. 

The  explanation  of  this  difference  between  the  earlier  and  the 
more  recent  statistics  on  this  sulyect  is  doubtless  furnished  by  the 
fact  that  the  first  operations  were  performed  in  cases  of  very  thin- 
walled  cysts,  free  from  solid  matter  and  uncomplicated  with  adlie- 
sions,  which,  therefore,  admitted  of  being  drawn  throngh  a  very 
small  opening.  An  incision  of  two  inches  in  length,  liowever, 
was  found  to  be  adequate  only  in  a  small  minority  of  cases ;  but 
80  soon  as  the  incision  was  made  somewhat  larger,  though  the 
principle  of  tapping  the  cyst  and  removing  it  through  as  small  an 
opening  as  possible  was  adhered  to,  yet  a  much  greater  amount 
of  interference  than  before  became  practicable,  adhesions  were 
sought  for  and  divided,  the  hand,  where  it  seemed  necessary,  was 
introduced  into  the  abdomen,  and  the  two  operations  have  now 
come  to  be  almost  on  a  level  in  point  of  danger.  It  is  not  tlie 
division  of  the  peritoneum  three  or  four  inches  more  or  less  that 
determines  the  fate  of  the  patient,  but  the  greater  or  less  degree 
of  meddling  which  has  been  necessary  to  the  completion  of  the 
operation.  This  last  fact,  too,  receives  a  further  illustration  from 
the  influences  which  the  character  of  the  tumor  exercises  upon 
the  fate  of  the  patient.  Operations  on  the  thin-walled  simple  cysts, 
which  are  most  easily  removed,  are  attended  by  the  smallest 
danger,  while  the  hazards  attendant  on  the  extirpation  of  multi- 
locular  cysts  and  solid  tumors  are  far  greater.  This  fact  is  very 
well  illustrated  by  a  tal)le  drawn  up  by  Mr.  Humphry,  of  Cam- 
bridge,^ in  which  he  divides  the  different  tumors  of  the  ovary  into 
three  classes,  and  shows  the  results  of  operations  for  their  removal 
to  have  been  as  follows  : 

RecoverfJ.      Difd. 

Simple  cysts, 16  6 

Cysts  with  aftor-growtlis — multilocular  cj-sts,  some 
described  as  cysts  with  solid  matter,  and  two  con- 
taining hair  and  teeth, 13  I) 

Solid  tumors,  called  lil)roiis,  scirrhous,  or  solid  with 

fluid,  or  solid  with  cysts, 7  10 

30  2) 

1  American  Journal,  April,  1850,  p.  337. 

2  In  a  pamphlet  entitled,  A  Report  nf  some  Cases  of  Operation:  reprinted  from 
the  Association  Medical  Journal.     Cambridge,  1856,  p.  40. 


476  REASONS  FOR  REJECTING 

I  find  also  that  on  dividing  ovarian  tumors  into  two  grand 
classes,  the  simple  c^'sts  on  the  one  hand,  and  the  compound 
cysts,  and  those  containing  more  or  less  solid  matter  on  the  other, 
the  following  results  are  obtained : 

Recoveries.  Deaths. 

Simple  cysts, 31  12 

Compound  cysts,  cysts  with  solid  matter, 

and  solid  tumors, 62  56 

93  68 

E'either  this  table  nor  the  preceding  is  referred  to  as  showing 
the  actual  mortality  from  ovariotonw,  which  possibly  may  not  be 
so  considerable  as  the  above  figures  represent,  but  merely  as  illus- 
trative of  the  comparative  risks  of  the  operation  according  as  the 
tumor  does  or  does  not  contain  any  considerable  amount  of  solid 
matter. 

From  this  wearisome  collection  of  details,  imperfect,  sometimes 
conflicting,  what  inference  may  we  draw  with  reference  to  the 
operation  of  ovariotomy ;  or  is,  perhaps,  no  conclusion  at  present 
possible,  and  must  the  decision  of  the  whole  question  be  adjourned 
to  a  future  time,  and  to  our  possession  of  better  information?  Some 
points,  indeed,  must  be  left  unsettled,  but  still  there  appears  to  me 
to  be  ground  sufhcient  for  some  conclusion,  and  that  I  fear  must 
be  unfavorable  to  the  performance  of  ovariotomy. 

The  chief  grounds  for  this  unfavorable  opinion  may  be  summed 
up  under  the  three  following  heads  : 

1st.  The  rate  of  mortality  from  the  operation  docs  not  appear  to 
be  in  course  of  diminution,  as  the  result  of  the  accumulated  expe- 
rience and  increased  dexterity  gained  by  its  frequent  repetition. 

2d.  Unlike  most  operations  in  which  anything  like  the  same 
rate  of  mortality  occurs,  it  is  scarcely  admissible  in  the  doul)tful 
or  desperate  cases  to  wjiich  the  Hippocratic  axiom  "ad  summos 
morbos,  summre  curationes,"  applies.  The  cases  in  which  it  may 
be  hoped  that  the  disease,  if  left  alone,  will  advance  tardily  or 
become  stationary,  those  in  which  something  may  be  anticipated 
from  other  less  hazardous  forms  ol'  interference,  are  the  very  cases 
that  yield  the  successes  on  which  it  has  been  sought  to  establish 
the  merits  of  ovariotomy.  It  is  ])roved  to  be  very  hazardous  indeed 
in  the  young;  it  is  believed  by  some  very  competent  surgeons  to 
be  attended  by  so  much  danger  in  those  past  the  middle  period  of 
life,  that  they  have  proposed  to  regard  the  operation  as  contraindi- 
cated  in  all  women  who  have  exceeded  the  age  of  forty-five  years. 
The  compound  cysts,  the  cysts  with  solid  matter,  the  malignant, 
and  quasi-malignant  growths,  those,  in  short,  whose  rate  of  prog- 
ress is  commonly  most  rapid,  which  are  the  most  burdensome  to 
the  patient,  are  attended  l3y  the  greatest  sufiering,  and  admit  of 
the  least  palliation  by  other  means,  are  precisely  the  cases  in  which 
the  surgeon  shrinks  most  from  ovariotomy.  In  the  table  drawn 
up  by  Mr.  Humphry,  who  himself  is  an  advocate  of  the  operation, 
cases  of  this  description  yielded,  when  operated  on,  19  deaths  to 


THE    OPERATIOX.  477 

20  recoveries;  in  my  own  table,  deduced  from  a  rather  larger  col- 
lection of  facts,  56  deaths  to  62  recoveries. 

3d.  Not  only  is  the  ojjeration  so  hazardous  in  those  very  cases 
where  it  is  really  most  called  for,  that  many  surgeons  shrink  then 
from  its  performance;  but  even  in  instances  that  may  be  selected 
as  the  most  favorable,  we  have  no  sure  grounds  on  which  to  rest 
our  prognosis  as  to  its  issue.  "It  is,  in  short,  a  venture  at  hap- 
hazard, since  the  medical  practitioner  is  never  able,  in  spite  of  the 
large  experience  already  accumulated,  to  foretell  the  issue  of  the 
operation  with  the  same  certainty  as  guides  him  in  undertaking 
other  serious  surgical  proceedings.  It  has,  indeed,  been  seen  in 
numerous  instances,  that  extirpation  of  the  ovary,  though  per- 
formed under  the  most  favorable  conditions,  and  by  the  most 
Bkilful  hand,  and  without  the  occurrence  of  any  untoward  acci- 
dent, has  yet  ended  in  a  few  days,  sometimes  even  in  a  few  hours, 
in  the  patient's  death." 

These  three  reasons,  the  high  mortality  which  experience  and 
dexterity  have  failed  to  lessen,  the  special  hazard  attendant  on 
those  cases  where  yet  the  operation  is  s])ecially  indicated,  and  the 
utter  uncertainty  in  which  we  find  ourselves,  even  in  the  most 
favorable  cases,  as  to  its  probable  result,  have  chiefly  influenced 
me  in  the  formation  of  my  opinion  as  to  the  general  inexpediency 
of  performing  ovariotomy. 

I  have  purposely  abstained  from  entering  on  one  argument  much 
relied  on  by  the  defenders  of  ovariotomy,  and  which  is  based  on 
the  allegation  that  many  other  operations  constantly  taught  and 
frequently  practised  are  attended  by  at  least  as  high  a  rate  of 
mortality.  I  exceedingly  doubt  the  correctness  of  some  of  the 
very  low  estimates  of  the  danger  of  ovariotomy  which  have  l)een 
sometimes  put  forth  ;  they  are  not  only  contradicted  by  the  figures 
which  I  adduced  in  a  former  part  of  this  lecture,  but  I  may  fur- 
ther add  that  Kiwisch,  who  himself  had  performed  the  operation, 
and  whose  weakness  it  certainly  was  not  to  underrate  successes, 
or  to  overrate  failures,'  expressed  his  belief  that  the  pro|»()rtion 
of  deaths  to  recoveries  is  really  as  5  to  4.  But  letting  that  pass, 
and  also  the  important  facts  that  otlier  operations  can  almost 
always  be  completed,  while  ovariotomy  is  frecpiently  left  unfin- 
ished, and  that  the  dangers  of  other  operations  can  be  estimated 
with  considerable  accuracy  beforeliand,  while  there  are  no  sure 
data  from  which  to  frame  the  prognosis  of  any  case  of  ovariotomy  ; 
I  would  object  to  the  sort  of  comparison  which  it  has  been  pro- 
posed to  institute,  on  the  gtound  that  there  is  no  such  resembhmco 
between  ovariotomy  and  those  other  operations  as  to  render  them 
fair  subjects  for  comparison.  The  propriety  of  the  performance 
of  tracheotomy  in  cases  of  croup  has  been  much  canvassed,  and 
many  persons  of  great  reputation  are  still  much  ojiposed  to  it. 
Its  defenders,  however,  have  not  sought  to  establish  their  point 
by  a  comparison  of  its  mortality  with  that  which  follows  ligature 

'  Op.  cii.,  vol.  ii,  p.  109. 


478  REASONS    FOR    REJECTING    THE    OPERATION 

of  the  subclavian  artery,  or  amputation  of  the  thigh.  Comparison 
can  be  instituted  only  between  things  which  bear  to  each  other 
some  resemblance,  and  the  only  operation  which  resembles  ovario- 
tomy is  the  Csesarean  section.  We  have  found,  however,  that  the 
danger  of  hemorrhage  is  greater,  that  of  peritonitis  almost  as  great, 
in  the  former,  and  that  the  smaller  rate  of  the  mortality  that  follows 
ovariotomy  is  to  be  attributed  almost  entirely  to  the  absence  of 
that  shock  which  in  the  C?esarean  section  is  inseparable  from  the 
violent  interference  with  the  process  of  labor  and  the  infliction  of 
injury  upon  the  uterus.^ 

But  I  do  not  wish  to  carry  out  a  comparison  between  ovario- 
tomy and  another  operation,  which,  though  not  without  some 
points  of  resemblance,  is  yetpertbrmed  in  different  circumstances, 
and  in  accordance  with  wholly  different  indications.  It  is  to  be 
compared  with  other  measures  for  the  cure  of  ovarian  dropsy  and 
ovarian  tumor,  just  as  the  value  of  tracheotomy  has  always  been 
measured  with  the  value  of  other  means  for  the  cure  of  croup,  and 
the  efforts  of  surgeons  and  physicians  have  been  directed  to  find 
out  trustworthy  indications  for  its  performance,  to  ascertain  the 
degree  of  additional  danger  which  it  brings  with  it,  as  well  as  the 
fresh  elenicnts  of  hope  which  it  brings  with  it  too. 

Ovariotomy  is  to  be  tested  by  its  results  as  compared  not  with 
those  of  amputation  at  the  liip  joint,  or  of  lithotomy,  or  of  the 
ligature  of  arteries,  but  with  those  of  tapping,  or  of  iodine  injec- 
tions, or  of  any  other  means  that  have  been  used  for  the  cure  of 
the  same  disease,  and  Avith  those,  too,  which  may  be  expected  if 
the  malady  is  left  untreated.  On  all  of  these  points  we  need  fur- 
ther and  more  exact  information  than  we  are  as  yet  possessed  of; 
and  till  we  obtain  this  the  question  of  ovariotomy  cannot  be  looked 
on  as  wholly  settled. 

At  present,  however,  we  are  not  in  a  position  to  lay  down  the 
indications  justifying  ovariotomy,  or  if  we  can  succeed  in  sketch- 
ing them  in  our  study  we  cannot  aver  that  they  exist  in  any  case 
which  we  meet  with  in  practice;  nor  can  we  venture  on  any  re- 
liable grounds  to  express  a  prognosis  as  to  the  issue  of  our  inter- 

'  I  myself  was  not  a  little  surprised  at  the  very  high  rate  of  mortality  which  a 
dispassionate  examination  of  the  subject  showed  to  be  attendant  on  ovariotomy,  and 
I  can  well  imagine  that  to  some  persons  who  have  been  accustomed  to  form  an  en- 
tirely different  estimate  of  its  dangers,  the  comparison  with  the  Caesarean  section 
may  seem  absolutely  untenable. 

While  these  sheets,  however,  were  passing  through  the  press,  I  received  vol.  iii, 
of  Scanzoni's  Beitrnr/e  zur  Geburtskunde,  &e.,  at  p.  99  of  which  is  an  account  by  Dr. 
Gustav  Simon  of  all  the  operations,  64  in  number,  in  which  ovariotomy  has  been 
attempted  or  actually  performed  in  Germany.  The  numerous  universities,  and  the 
great  activity  of  literary  commerce  in  that  country,  render  it  probable  that  all 
cases,  unfavorable  as  well  as  successful,  will  be  reported  in  juster  proportif>n  there 
than  elsewhere.  These  64  cases,  however,  yield  "  12  radical  cures,  4()  o))erations 
with  fatal  issue,  and  6,  the  benefits  of  which  were  either  questionable,  temporary, 
or  which  turned  out  utter  failures  "  The  fatal  cases,  then,  form  72  per  cent,  of 
the  total  number,  a  mortality  which,  as  Dr.  Simon  observes,  p.  108,  is  "even 
greater  than  that  of  the  Cfesarean  section,  under  which,  according  to  Kayser's  es- 
timate, 63  per  cent.,  according  to  other  authorities  two-thirds,  of  the  patients  are 
lost." 


RECONSIDERED.  479 

ference  even  when  the  operation  has  heen  performed  with  the 
greatest  success  and  the  fewest  difficulties.  Till  we  can  do  this, 
however,  the  operation  seems  to  me  to  take  its  place  by  the  side 
of  those  exceptional  proceedings,  the  expediency  of  which  must 
he  determined  by  each  one  for  himself  after  a  careful  considera- 
tion of  the  peculiarities  of  the  case  and  the  idiosyncrasies  of  the 
patient. 

It  is  between  six  and  seven  years  ago  since  I  expressed  these 
opinions.  I  have  thought  it  right  to  reproduce  them  now,  word 
for  word,  and  to  repeat  the  grounds  on  which  they  rested.  I  have 
done  so  because  these  opinions  are  still  in  the  main  those  of  the 
highest  authorities  in  France  and  Germany,  and  it  is  only  in  this 
country  and  m  America,  that  any  important  additional  experience 
has  been  attained  concerning  the  operation  and  its  results. 

Even  in  England,  most  of  the  former  opponents  of  ovariotomy 
retain  the  unfavorable  opinion  which  they  had  already  expressed, 
but  I  am  not  aware  that  anvthino;  whatever  has  been  done,  or  even 
attempted  by  them  to  devise  other  and  less  hazardous  proceedings 
for  the  cure  of  ovarian  disease,  or  even  for  retardins:  its  progress; 
and  iodine  injections,  which  seemed  to  promise  so  much,  have 
been  allowed  to  fall  into  disuse,  almost  without  an  attempt  to 
ascertain  their  real  value.  Ovarian  disease,  then,  remains,  as  far 
as  curative  measures  are  concerned,  just  where  it  was  seven  years 
ago  ;  a  deeper  conviction  of  the  utter  fruitlessness  alike  of  internal 
remedies,  and  of  outward  ap})lications  being  all  that  the  exjierience 
of  these  seven  years  has  taught  us. 

It  becomes,  then,  of  the  more  importance  to  inquire  whether 
this  gloomy  picture  admits  of  no  alleviation,  whether  the  hazard- 
ous operation  of  ovariotomy  has  lost  none  of  its  dangers,  whether 
its  attempt  is  attended  by  the  same  uncertaint}'  as  l)efore,  and 
whether  recoveries  from  it  are  still  limited  to  cases  where  its  ne- 
cessity was  the  least  urgent? 

I  am  bound  to  admit  that  to  all  of  these  questions  the  reply 
must  be  much  more  favorable  than  it  was  seven  years  ago ;  that 
the  persevering  etibrts  of  tlie  advocates  of  the  operation  have  led 
to  a  greater  accuracy  of  diagnosis;  to  a  more  careful  selection  of 
cases  ;  to  a  removal  of  some  of  the  dangers  of  the  operation  ;  to 
the  discovery  of  the  comparative  safety  of  some  proceedings,  such 
as  the  return  of  the  pedicle  with  the  ligature  around  it  into  the 
abdomen,  from  which  surgeons  would  have  shrunk  as  nothing 
less  than  fatal,  and  to  a  more  judicious  after-treatment;  and,  con- 
sequently, that  ovariotomy  has  increased  in  certainty,  and  gained 
in  safety. 

This  improvement  in  the  results  of  ovariotoni}-,  however,  is  less 
apparent  than  might  be  expected  if  we  confine  our  attention  to 
those  cases  where  the  operation  has  been  actually  completed. 
The  mortality  in  cases  of  completed  ovariotomy,  according  to  Dr. 
Atlee,  down  to  the  year  1850,  may  be  stated  at  32. 'JT  per  cent.; 
the  mortality  of  the  operations  of  Sir.  B.  Brown,  Mr.  irutchinson, 
Dr.  T.  Smith,  and  Mr.  iSpcncer  Wells,  all  of  which  have  been  per- 


480  REASONS    FOR    REJECTING    IHE    OPERATION 

formed  subsequent  to  that  time,  amount  to  30.3.*  The  results  of 
Mr.  Spencer  Wells's  cases,  subsequent  to  the  publication  of  his 
paper  in  the  Medico- Chirurgical  Transactions^  show  no  progressive 
diminution  of  the  dangers  of  ovariotomy.  Of  his  first  50  cases, 
17  died ;  of  his  last^  43,  15  died ;  and  the  fractional  difference 
between  the  mortality  of  the  two  series  of  cases  shows  a  slight 
accidental  increase  of  the  death-rate  of  the  latter.  A  division, 
too,  of  such  of  the  cases  tabulated  in  the  appendix  to  Mr.  Clay's 
translation  of  Kiwisch  on  Diseases  of  the  Ovaries,  as  have  any  date 
assigned  to  them,  into  two  classes,  according  as  ovariotomy  was 
performed  before  1855,  or  afterwards,  would  even  show  that  the 
fatality  of  completed  operations  had  increased  from  43  to  46  per 
cent.  I  do  not  for  a  moment  believe  this  to  be  the  case ;  but  I 
refer  to  this  apparent  result  as  a  proof  that  the  fatality  of  the  op- 
eration has  not  greath/  diminished,  if  we  regard  those  cases  only 
in  which  it  was  actually  completed. 

The  nature  of  the  risk,  too,  remains  the  same.  Life  does  not 
seem  in  fatal  cases  to  be  prolonged  much  beyond  the  period  which 
it  attained  to  before. 

Of  68  fatal  cases  which  I  had  found  mention  of  seven  years  ago, 
37  or  54.4  per  cent,  terminated  in  less  than  72  hours.  In  86  of 
150  fatal  cases,  or  in  50.6  per  cent.,  the  duration  of  life,  as  stated 
in  Dr.  Clay's  table,  was  likewise  less  than  72  hours. 

In  59  of  the  fatal  cases  I  found  the  cause  of  death  stated. 

'  In  '29,  or  49  per  cent.,  death  took  place  from  peritonitis. 

"  1.3,  "  22        "  "  "  hemorrhage. 

'«     2,  "   ...        "  "  "  shock. 

In  139  of  Dr.  Clay's  cases  the  cause  of  death  is  given,  and  is  stated 
to  have  been : 

Peritonitis, in  64,  or  46  per  cent. 

Hemorrhage^  and  shock,         "  49,  "  35.2     " 

It  is  needless  to  say  that  these  figures  are  dealt  with  not  as 
representing  absolute  facts,  but  merely  as  showing  the  direction 
to  which  in([uiry  on  the  whole  is  tending.  They  guide  us  aright, 
not  as  the  compass  does,  which  now  enables  the  mariner  to  steer 
with  absolute  certainty,  but  rather  as  in  old  times  the  stars  did, 
when  they  taught  him,  not  without  doubt  and  misgiving,  yet  in 
the  main  correctly,  whither  to  shape  his  course. 

It  seems,  then,  that  completed  ovariotomy  is  nearly  as  fatal  as 
before ;  that  life  is  prolonged  but  little  longer  than  it  was  formerly 
in  fatal  cases;  and  the  causes  of  death  are  much  the  same  as  they 
Avere,  though  I  have  no  doubt  that,  owing  to  improvement  in  the 
details  of  the  operations,  there  has  been  a  reduction  in  the  risk  of 
mere  hemorrhage. 

1  Deduced  from  numbers  given  by  Dr.  Graily  Hewitt,  oji.  cii.,  p.  588. 

2  The  result  of  which  Mr.  Wells  kindly  communicated  to  me  by  letter  in  April 
of  the  present  j^car,  1864. 

*  The  mortality  from  hemorrhage  alone  is  said  to  have  been  24 ;  from  shock 
alone  25. 


I 


RECONSIDERED.  481 

The  great  advance  wliich  has  been  made,  however,  appears  in 
the  certainty  of  diagnosis  that  has  now  been  attained,  as  seen  by 
the  far  fewer  instances  where  tlie  operation  has  been  commenced 
and  abandoned,  either  from  adhesions,  or  from  some  other  cause 
interfering  with  its  completion. 

Ileferriug  again  to  Dr.  Clay's  tables,  I  find  unfinished  operations: 

Before  1855.  Sin(-e  1855. 

Cases.   Died.  Cases.  Died. 

Partial  excision,  tumor.s  being  ovarian, 23      13  1        1 

"  "  e.xlra-ovarian, 12        9         

Abandoned  on  account  of  adhesion,  tumors  being  ovarian,      58      12  .5       3 

"  "  extra-ovarian,      14        5         

107     39  r,       4 

This  table,  again,  is  to  be  taken  with  the  cautions  already  given, 
for  I  myself  know  of  one  non  reported  case  of  death  after  partial 
extirpation  of  a  fibrous  tumor  of  the  uterus;  and  Mr.  Spencer 
"Wells'  mentions  six  cases  of  exploratory  incision,  or  of  attempted 
operation,  of  which  one  had  a  fatal  termination. 

The  stigma  of  uncertainty,  then,  which  formerly  rested  on  the 
operation,  may  be  regarded  as  now  almost  or  altogether  done  away 
with;  and  the  experienced  surgeon  may  begin  its  performance 
without  more  uncertainty  as  to  his  ability  to  complete  it  than 
accompanies  other  of  the  capital  operations  of  surgery. 

Some  of  the  oi)jections  against  ovariotomy  appear  to  have  been 
the  result  of  an  over-hasty  generalization.  It  does  not  appear  that 
any  age  furnishes  a  positive  contraindication  of  its  performance ; 
and  as  we  deal  witli  altered  figures  we  arrive  at  difterent  results, 
which  prove,  if  nothing  else,  at  least  the  absence  of  any  law  by 
which  the  age  of  the  patient  governs  the  result  of  tlie  operation. 

In  Dr.  Clay's  table  the  age  of  the  patient  is  given  in  274  cases, 
which  may  be  thus  distributed: 

Between  18  and  30  years,  120  operations,  58  deaths. 

"        30    "    40      "        81  "  3(i       " 

"        40    "    50      "        4(5  "  23       " 

"        50    "    60      "        23  "  11       " 

Above  60    "     ...      u  4  u  j       u 

It  is  curious,  too,  with  reference  to  the  alleged  extreme' fatalit}' 
of  ovariotomy  in  the  young,  that  8  of  Mr.  Spencer  Wells's  So  pub- 
lished successes,  occurred  in  young  women  between  the  ages  of  17 
and  25  years,  while  no  death  took  place  under  the  age  of  '26. 

Another  objection  has  been  based  on  the  assumption  that  the 
only  cases  wliich  lurnish  results  sufficiently  encoui'aging  to  Justity 
the  operation,  are  cases  of  sim])le  cysts,  which  usually  increase  the 
least  rapidly,  exercise  the  least  injurious  inlluence  on  the  consti- 
tution, and  are  also  most  amenable  to  other  modes  of  treatment. 
Such  cases,  too,  are  probably  the  most  i'avorable  for  operation, 
though  here,  again,  a  little  change  in  the  data  yields  a  dilferent 
result;  but  in  fact  by  far  the  greater  majority  of  the  instances  in 

1  Med.  Chir.  Transncfions,  vol.  xlvi,  18G0,  p.  49. 
31 


482  REASONS    FOR    REJECTING    THE    OPERATION 

which  ovariotomy  is  performed  are  the  more  common  cases  where 
the  c^ysts  are  compound,  with  a  more  or  less  considerable  quantity 
of  solid  matter.  In  only  2  of  Mr.  Wells's  33  cases  of  successful 
ovariotomy  was  the  tumor  a  simple  cyst;  in  the  remaining  31 
cases  the  growths  were  multilocular,  with  a  varying  amount  of 
solid  matter. 

I^either  the  patient's  age  then,  nor  the  nature  of  the  tumor, 
can  be  regarded  as  of  itself  prohibiting  the  operation  ;  and  we  are 
clearly  advancing  into  the  region  of  certainty,  when,  instead  of 
arbitrary  laws  deduced  from  the  results  of  a  limited  number  of 
figures,  we  become  able  to  lay  down  indications  for  doing  or  ab- 
staining from  the  operation  founded  on  the  general  principles  of 
medicine  and  surgery. 

I  think,  then,  that  we  are  now  bound  to  admit  ovariotomy  as 
one  of  the  legitimate  operations  of  surgery;  as  holding  out  a 
prospect  and  a  daily  brightening  i)rospect  of  escape  from  a  painful 
and  inevitable  death,  which  at  last  indeed  becomes  welcome,  only 
because  the  road  that  leads  to  it  conducts  the  patient  through  such 
utter  misery.  , 

Perhaps  we  may  sum  up  the  indications  and  contraindications 
for  the  operation  somewhat  thus: 

1st.  It  is  not  to  be  performed  in  an}^  case  of  single  cyst  which  is 
not  increasing,  or  is  increasing  but  slowly,  while  it  has  not  as  yet 
interfered  with  the  patient's  general  health.  In  other  words,  life 
is  not  to  be  jeopardized  for  a  mere  discomfort. 

2(1.  It  is  not  as  a  general  rule  to  be  performed  until  after  the 
cyst  has  been  tapped  once.  The  reasons  for  this  caution  are  three- 
fold. In  some  rare  cases  the  fluid  does  not  re-collect ;  the  amount 
of  constitutional  disturbance  which  follows  tapping  would  be  some 
index  to  the  amount  that  might  be  apprehended  from  the  more 
serious  operation  of  extirpating  the  tumor;  and  lastly,  when  the 
cyst  is  emptied,  and  during  the  process  of  its  refilling,  its  relations, 
and  the  presence  or  absence  of  adhesions,  especially  to  parts  within 
the  ])elvis,  can  be  more  readily  ascertained. 

I  doubt  whether,  in  the  case  of  simple  cysts,  ovariotomy  ought 
not  to  be  further  limited  to  cases  in  wliich  trial  has  been  made  of 
iodine  injections  suflicient  to  ascertain  them  to  be  inefiicacious,  or 
to  prove  them  to  be  unsafe. 

3d.  It  is  7iot  to  be  performed  in  any  case  in  which  a  tumor  is 
felt  in  the  pelvis,  retaining  the  same  situation  but  little  changed 
after  tapping,  and  from  which,  by  means  of  the  sound,  the  uterus 
cannot  be  distinctly  isolated. 

4th.  It  is  further  contraindicated  by  the  presence  of  albumen  in 
the  urine,  or  at  any  rate  by  the  persistence  of  any  trace  of  it  after 
tapping,  and  also  by  the  early  occurrence  of  swelling  of  the  legs, 
and  by  the  presence  of  any  considerable  quantity  of  ascitic  fluid 
in  the  abdominal  cavity. 

5th.  And  lastly,  its  success  is  rendered  extremely  doubtfid  by 
the  previous  occurrence  of  cyst-inflammation,  and  general  perito- 
nitis, as  evidenced  by  attacks  of  sickness,  shivering,  fever,  and 


RECONSIDERED.  483 

abdominal  pain,  and  by  the  presence  of  pus  in  the  fluid  evacuated 
by  puncture.  The  fact  of  a  })atient  having  had  occasional  attacks 
of  abdominal  pain,  of  short  duration,  unattended  by  fever,  or  by 
abiding  tenderness,  does  not  contraindicate  the  operation,  since 
such  attacks  occur  independently  of  inflammation. 

On  the  other  hand  it  is  not  contraindicated. — 

1st.  By  the  patient's  youth  or  age,  nor  by  the  fact  of  her  having 
previously  undergone  several  tappings,  nor  by  the  irregularity  or 
suppression  of  the  menses,  since  complete  menstrual  suppression 
does  not  prove  both  ovaries  to  be  implicated. 

2d.  It  is  justifiable  and  to  be  recommended  in  all  cases  of 
ovarian  tumor,  wliatever  be  its  structure,  and  whether  its  existence 
be  of  long  or  short  duration,  and  whether  tapping  has  or  has  not 
been  frequently  resorted  to,  where  the  disease  is  steadily  and  pro- 
gressively increasing,  and  when  the  [)atient's  health  is  beginning 
to  sutler  from  this  increase,  but  as  far  as  can  be  ascertained  from 
no  other  cause  independent  of  the  local  mischief. 

Something,  indeed,  I  think  much  of  our  conduct  must  be  gov- 
erned by  the  state  of  the  patient's  own  mind  and  wishes;  by  the 
calmness  with  which  she  can  regard  the  possible  failure  of  the 
operation,  and  the  sudden  entering  on  the  "unknown  land;"  by 
the  strength  of  the  ties  which  bind  her  to  the  world,  and  make 
her  desirous  to  continue  in  it,  and  by  the  spirit  of  hopefulness 
that  may  enable  her  to  look  beyond  the  risk  of  the  few  days,  to 
the  perfect  health  in  future  years  which  will  be  the  reward  of  a 
successful  venture.  Dread  of  the  issue  is  a  bad  state  of  mind  in 
which  to  undergo  an  opei-ation  of  this  magnitude ;  I  am  not  sure 
but  tluit  inditterence  is  even  worse:  I  am  quite  certain  that  moral 
considerations  must  be  weighed  as  carefully  as  those  furnished  by 
the  character  of  the  tumor,  or  the  history  of  its  growth. 

I  cannot  expect  that  the  reasons  which  have  seemed  to  me 
conclusive  in  favor  of  ovariotomy  should  appear  to  others  equally 
cogent;  though  I  quite  expect  that  tlie  next  seven  years  will,  as 
the  past  have'clone,  lessen  the  objections  to  its  performance,  and 
increase  the  evidence  in  its  iavor.  So  long,  however,  as  there 
continues  to  be  room  for  diflerence  of  opinion  on  the  subject,  the 
caution  is  not  superfluous  which  I  ventured  to  suggest  seven  years 
ago  with  reference  to  the  grievous  injury  that  is  done,  both  to  the 
advance  of  medical  knowledge  and  to  the  standing  of  our  pro- 
fession with  the  public,  by  tlie  practice  of  treating  some  of  these 
questions  as  though  they  were  questions  of  moral  right  or  wrong. 
It  would  seem,  from  -what  has  sometimes  been  said  on  the  subject, 
almost  as  if  ovariotomy  could  not  be  defended  save  from  some 
sinister  end,  nor  its  ex[)ediency  be  doubted  except  from  a  moral 
obliquity  rendered  excusable  only  by  hopeless  dulncss.  Ik'licl  in 
each  other's  integrity  of  i)urposc  seems  to  me  essential  to  our 
eliciting  truth  by  discussion  ;  and  I  see  no  reason  why  I  am  to 
suspect  another  of  being  less  mindful  of  our  common  duty  to 
humanity  because  he  tries  to  relieve  suflering  or  to  prolong  life 
by  some  means  in  which  I  have  not  the  same  conficlcncc.     The 


484  INFLAMMATION    OF    THE    BLADDER. 

odium  theologicum  has  at  least  age  and  respectability  in  its  favor ; 
I  fear  the  inimortal  quarrel  between  Dr.  Slop  and  Susannah  has 
gone  far  to  render  the  odium  obstetricantium  simply  ridiculous. 


LECTURE    XXXI. 

AFFECTIONS  OF  THE  FEMALE  BLADDEE. 

Inflammation  of  the  bladder,  its  acute  and  subacute  form  ;  the  latter  the 
more  frequent — sometimes  connected  with  tubercular  disease  of  the  kidney,  or 
with  chronic  nephritis.     Chronic  cystitis. 

Treatment  of  the  ditterent  forms  of  the  disease. 

Vesico-vaginal  Fistula.  Remarks  on  its  prevention,  and  on  the  treatment 
preliminary  to  an  operation  for  its  cure. 

iNTESTINO-VKfSlCAL  FiSTULA, 

Malignant  Disease  of  the  bladder. 

It  may  at  first  sight  appear  that  the  affections  of  the  urinary 
organs  do  not  deserve  a  phace  in  a  course  of  lectures  on  the 
diseases  of  women.  To  a  certain  extent,  too,  the  objection  is  well- 
founded  ;  and  I  will  therefore  state  at  once  that  it  is  not  n)y  in- 
tention to  enter  on  the  consideration  of  the  whole  of  so  extensive 
a  subject,  or  to  occupy  your  time  with  the  minute  study  of  diseases 
which  are  common  to  both  sexes,  which  run  in  both  a  similar 
course,  and  manifest  themselves  ])y  the  same  symptoms. 

There  are,  however,  some  disorders  of  the  urinary  apparatus 
almost  peculiar  to  the  female  sex,  and  others  whose  causes  and 
whose  course  are  different  in  women  and  in  men,  and  it  is  to  these, 
and  these  only,  that  I  propose  to  call  your  attention. 

Reference  has  been  frequently  made  to  the  manner  in  which 
the  bladder  participates  in  the  disorder  even  of  the  functions  of 
the  womb,  and  instances  have  been  adduced  of  the  advance  of 
serious  organic  disease  of  the  uterus,  unannounced  by  other  symp- 
toms than  those  which  an  irritable  state  of  the  bladder,  or  a  some- 
what altered  character  of  the  urinary  secretion  presented.  Nor 
is  this  all,  but  not  infrequently  the  subsidence  of  uterine  disease 
leaves  behind  some  impairment  of  the  functions  of  the  bladder; 
and  constant  irritability  of  the  organ,  pain  in  micturition,  or  occa- 
sional difficulty  in  voiding  the  urine,  remain  as  the  after-effects  of 
some  not  very  severe  attack  of  inflammation  of  the  womb,  or  of 
its  appendages. 

Inflammation^  indeed,  beginning  in  adjacent  parts,  and  by  its  ex- 
tension involving  the  bladder,  plays  a  very  important  part  among 
the  causes  of  disorder  of  the  urinary  organs  in  woman.  It  is  thus 
that  irritability  of  the  bladder  is  not  infrequently  left  behind  after 
an  attack  of  vaginitis,  or  follows  on  a  miscarriage  or  a  tedious 
labor.  The  recovery  in  such  cases  seems  at  first  almost  complete; 
but  the  slightest  cause,  such  as  the  natural  congestion  of  the  pelvic 


SYMPTOMS   AND    COURSE   OF    CHRONIC    CYSTITIS.        485 

viscera  which  accorapanies  menstruation,  accidental  exposure  to 
cold,  or  the  occurrence  of  pregnancy,  suffices  to  reproduce  the 
frequent,  and  difficult,  and  painful  micturition,  and  to  render  tlie 
urine  once  more  turbid,  charged  with  the  phosphates,  and  aljoniid- 
ing  in  deposits  of  pus  or  mucus.  Such  symptoms,  too,  continue 
for  months  or  years  varying  in  degree,  now  worse  now  better,  a 
life-long  source  of  discomfort,  tending  rather  to  increase  than  to 
diminish. 

Acute  Cystitis  has  never  come  under  my  notice  except  after  de- 
livery, when  its  symptoms  have  been  almost  lost  in  those  of  the 
graver  inflammation  of  the  uterus,  or  of  the  peritoneum,  -with 
which  it  was  associated.  These  complications,  when  severe,  often 
terminate  in  death,  and  then  the  interior  of  tlie  bladder  is  not  in- 
frequently found  denuded  to  a  great  extent  of  its  mucous  mem- 
brane, which  hangs  in  dark,  sloughy  shreds  and  patches  from  an 
intensely  congested  surface ;  its  state  closely  resembling  that  pre- 
sented by  the  interior  of  the  womb  itself. 

For  the  most  part,  however,  the  injury  inflicted  on  the  bladder, 
is  less  grave,  or  at  least  more  circumscribed,  and,  not  being  at- 
tended by  serious  aftection  of  the  womb  itself,  does  not  prove 
dangerous  to  life.  At  some  one  point  where  during  labor  the 
pressure  of  the  foetal  head  was  most  considerable  the  tissue  dies, 
and  the  patient's  distress  and  dysuria  find  a  melancholy  allevia- 
tion in  the  unconscious  outflow  of  the  urine.  The  inflammation 
has  ended  in  destruction  of  tissue  and  in  the  formation  of  a 
vesi CO- vaginal  fistula,  but  it  has  ended;  and  suftering  of  a  new 
kind  now  takes  the  place  of  that  which  the  patient  had  before  en- 
dured. But  this  accident  is  happily  not  the  most  usual  result  of 
inflammation  of  the  bladder,  the  long-continued  pressure  on  the 
organ,  or  the  neglect  to  employ  the  catheter,  or  the  inflammation 
of  the  uterus  leading  to  a  sort  of  .s-wSacu^e  cijxtitis,  very  painful  and 
very  difficult  of  cure,  but  neither  destroying  life  nor  condemning 
the  patient  to  permanent  incontinence  of  urine 

Tlie  history  of  such  cases  is  generally  something  of  this  sort. 
Labor,  or  perhaps  abortion,  was  followed  by  an  attack  of  pain  in 
the  lower  part  of  the  aV)domen,  with  much  tenderness  on  pressure, 
and  with  difficulty  and  pain  in  voiding  the  urine,  or  sometimes 
with  actual  inability  to  pass  it.  Leeches  and  other  appropriate 
treatment  had  probably  removed  the  other  symptoms  and  miti- 
gated those  referred  to  the  bladder;  but  still  the  patient  finds 
herself  distressed  by  a  constant  desire  to  pass  water,  which  she  is 
unable  to  retain  above  twenty  minutes  or  half  an  hour,  the  wish 
to  void  it  being  uncontrollable,  though  the  pain  in  the  act  itself 
is  liable  to  considerable  variations.  The  urine  is  alkaline,  often 
intensely  so,  loaded  with  the  phosphates,  and  containing  also  a 
large  quantity  of  pus  or  mucus,  the  amount  of  which,  however, 
frequently  seems  to  the  naked  eye  more  considerable  than  it  really 
is  from  the  abundant  deposit  of  phosphates  with  which  it  is 
mingled. 

The  constant  direction  of  the  mind  to  the  urinary  function  no 


48G  CYSTITIS    CONSEQUENT    ON 

doubt  increases  the  frequency  of  the  desire  to  empty  the  bladder, 
and  the  incessant  calls  to  pass  water  by  night  as  well  as  by  day 
break  down  the  patient's  health  and  grievously  embitter  her  exist- 
ence. Every  circumstance,  too,  which  adds  to  the  congestion 
of  the  pelvic  viscera  exaggerates  the  irritability  of  the  bhxdder. 
Hence  the  menstrual  period  is  always  a  time  of  increased  discom- 
fort; hence,  too,  the  symptoms  are  sure  to  be  aggravated  by  the 
patient's  return  to  her  husband's  bed,  and  the  occurrence  of  preg- 
nancy is  invariably  accompanied  by  an  exacerbation  of  all  her 
sufferings,  and  by  a  real  advance  of  her  disease. 

Exaniination  of  the  patient  seldom  fails  to  confirm  the  diagnosis 
to  which  a  mere  detail  of  the  symi»toms  would  lead  us,  though  it 
must  be  borne  in  mind  that,  according  to  their  own  preconceived 
notions,  patients  will  sometimes  give  greater  prominence  to  the 
indications  of  disease  either  of  the  womb  or  of  the  bladder,  and 
will,  till  closely  questioned,  say  little  concerning  those  other  symp- 
toms which,  though  perhaps  not  less  distressing,  had  yet  impressed 
them  less,  because  they  were  supposed  to  be  subordinate  in  im- 
portance or  secondary  in  the  order  of  their  occurrence.  Tender- 
ness on  pressure  over  the  pubes  is  a  common  attendant  on  inflam- 
mation of  the  bladder,  though,  owing  to  the  contracted  state  of 
the  organ  this  symptom  is  not  always  appreciable  unless  the  pres- 
sure is  made  directly  downwards  into  the  pelvic  cavity.  The 
finger  in  the  vagina  generally  ascertains  all  the  parts  to  be  unduly 
sensitive,  though  often  there  is  no  perceptible  alteration  in  their 
condition.  The  mere  increase  of  sensibility,  too,  is  not  always 
manifest  unless  pressure  is  made  forwards  against  the  anterior 
vaginal  wall ;  but  then  the  suffering  which  is  at  once  experienced 
points  to  the  real  seat  of  mischief,  wliile  the  introduction  of  the 
catheter  excites  pain  almost  intolerable  from  its  severity,  and 
which  often  abides  for  many  hours. 

In  the  higher  classes  of  society  the  ailment  scarcely  reaches  such 
a  degree  of  severity  as  is  here  described.  Appropriate  treatment 
in  the  first  instance,  and  prolonged  care  afterwards,  if  they  do  not 
completely  remove  the  disease,  in  general  so  greatly  mitigate  it 
as  to  reduce  it  to,  at  the  worst,  a  painful  infirmity.  Among  the 
poor,  however,  the  case  is  very  different ;  for  the  disease  at  first 
neglected,  is  often  but  little  heeded  afterwards,  and  when  the  pa- 
tient has  recovered  from  the  more  urgent  consequences  of  the 
delivery  or  the  miscarriage  in  which  her  sufferings  originated,  she 
is  compelled  to  return  at  once  to  her  ordinary  duties.  Causes,  in 
themselves  trifling,  a  slight  exposure  to  cold,  inability  to  rest 
during  a  menstrual  period,  the  ordinary  incidents  of  married  life, 
sexual  intercourse,  pregnancy,  abortion,  or  delivery,  add  to  the 
congestion  of  the  bladde-r,  and  increase  its  irritability.  At  length 
the  patient  seeks  admission  into  a  hospital,  but  stays  there  only 
long  enough  to  gain  some  slight  relief,  not  long  enough  to  make 
any  real  advance  tO"wards  cure.  The  mucous  membrane  of  the 
bladder  becomes  ulcerated,  and  blood  in  small  quantities  appears 
in  the  urine,  in  addition  to  the  deposits  of  pus  and  of  the  phos- 


DISEASE    OF    THE     KIDNEYS.  487 

phates  which  it  before  contained.  The  bladder  is  so  contracted 
that  it  can  no  longer  hold  half  an  ounce  of  urine  ;  and  sometimes 
the  ureters  themselves  become  dilated,  as  if  tbe  urine  sojourned 
there  with  less  distress  to  the  patient,  nor  do  the  kidneys  remain 
exempt  from  a  participation  in  the  mischief.  Their  substance 
wastes,  while  the  distinction  between  tlie  cortical  and  medullary 
portion  becomes  less  obvious  than  natural;  they  become  saccu- 
lated, and  turbid  urine  is  generally  found  within  them,  while  their 
lining  membrane  is  highly  vascular,  and  the  urine  is  sometimes 
actually  purulent,  or  in  otlier  words,  y.yelitis  follows  the  disease  of 
the  bladdder,  and  with  it  atroi>liy  of  the  })roper  tissue  of  the  kid- 
ney's. The  mode  of  death  in  these  cases  is  very  various.  Some- 
times the  patient  sinks  exhausted,  and,  having  long  been  feeble, 
passes  away  quietly  and  unexpectedly  ;  at  other  times  the  irrita- 
bility of  the  stomach  becomes  so  extreme  that  all  food  and  all 
medicine  are  alike  rejected.  Sometimes  much  suffering  precedes 
death,  and  I  remember  one  poor  woman  who  all  day  and  all  night 
long  sat  crouched  on  a  chamber  utensil,  so  incessant  was  the  call 
to  empty  her  bladder,  while  she  com]*lained  ol'  the  urine  as  it 
passed  scalding  her  like  molten  lead.  She  remained  tlius,  sway- 
ing herself  to  and  fro  in  her  agony,  unrelieved  by  even  the  laigest 
doses  of  opium,  till  as  life  waned  her  pains  lessened  too,  and  at 
length  she  lay  down  for  the  first  time  for  many  weeks,  worn  out 
and  weary,  to  die.  In  other  cases  the  kidneys  cease  by  degrees 
to  perform  their  functions,  and  at  last  no  urine  at  all  is  secreted, 
and  typhoid  symptoms  come  on,  under  which  the  patient  sinks 
rapidl3\ 

There  can  b^no  doubt  but  that  some  of  these  cases  are  con- 
nected with  tubercular  disease  of  the  kidney,'  the  affection  of  the 
bladder  being  secondary'  and  subordinate,  and  this  even  tlnMigh 
the  symptoms  during  life  have  pointed  almost  exclusively  to  the 
bladder  as  the  seat  of  mischief.  It  is  probable,  too,  that  in  other 
instances  the  irritation  of  the  bladder  consequent  on  the  miscarriage 
or  the  labor  from  which  the  patient  dates  the  commencement  of 
her  illness,  may  have  been  the  exciting  cause  of  the  subsecpient 
mischief,  and  that  the  tubercular  deposit  in  the  kidney  has  really 
been  occasioned  by  the  previous  cystitis.     I  have  no  means  of 

1  Sir  15.  C.  Brodic's  work  on  Disensef;  of  ihe  Uvinnn/  On/ons,  contiiins,  nt  p.  133, 
a  short  but  valuable  chapter  on  symptoms  aftVctint;  the  bladder  in  consequence  of 
disease  in  the  kidney,  and  some  of  the  cases  which  he  relates  appear  to  be  instances 
of  tuberculous  disease  of  that  origan.  Kokitansky,  op.  cU.,  vol.  ii,  p.  443,  does  but 
just  refer  to  tubercular  deposit  in  the  kidney  as  a  secondary  occurrence,  and  one 
more  common  in  the  male  than  in  the  female ;  whih*  Louis.  lirrhn-clirx  utir  la 
P/ifJiisic,  p.  129,  refers  to  the  existence  of  considerable  tuberculous  disease  of  the 
kidney  as  a  rare  occurrence.  Kayer,  Maladies drs  lirins,  vol.  iii,  p.  filH,  treats  very 
fully  of  the  affection,  but  lie  also  speaks  of  it  as  bcint,'  secondary  to  tuberculous 
disease  elsewhere,  and  for  the  most  part  also  to  such  disease  in  a  ratln'r  advanced 
form.  Dr.  Prout,  On  Stomach  and  Urinan/  Disrasrs,  3d  editiun.  pp.  393-400,  no- 
tices another  class  of  cases  not  connected  with  tubercle,  concerninjj  wbidi  lie  con- 
fesses his  own  knowledge  to  be  but  incomplete.  Such  cases  are  not  very  rnre  in 
women  ;  they  will  deserve  a  careful  investigation.  In  my  hands,  I  must  confess 
that  they  have  been  the  opprobria  of  the  ward. 


488  TREATMENT    OF 

judging  of  the  comparative  frequency  of  tubercular  disease  of  the 
kidne}^  in  the  two  sexes  ;  it  certainly  is  not  common  in  the  female; 
or,  perhaps,  it  may  be  that  one  comparatively  seldom  sees  the  ter- 
mination of  a  disease  so  chronic  as  this  would  appear  often  to  be, 
causeless  irritability  of  bladder  sometimes  occasioning  distress 
and  proving  rebellious  to  treatment  for  years  before  the  more 
serious  symptoms  set  in.  Possibly  the  more  acute  symptoms  co- 
incide with  the  extension  of  mischief  to  the  bladder,  though  its 
amount  varies  greatly;  for  while  I  have  sometimes  found  nothing 
more  than  intense  congestion  of  its  lining  membrane,  I  have  also 
in  other  instances  seen  it  ulcerated,  with  patches  of  Ij-mph  on  its 
surface,  or  have  even  found  it  completely  destroyed,  the  muscular 
coat  being  everywhere  exposed,  and  the  broad  bands  of  muscular 
fibre  of  a  vivid  red  crossing  the  interior  of  the  organ  in  all  direc- 
tions. Once,  too,  the  mischief  had  passed  even  this  point ;  the 
bladder  was  perforated  at  one  spot  near  its  upper  and  posterior 
part,  where  the  adhesion  of  a  portion  of  omentum  to  it  had  alone 
prevented  the  escape  of  its  contents,  and  in  other  parts  the  peri- 
toneum alone  remained  entire.  In  this  case,  too,  the  disease  had 
extended  even  to  the  urethra,  the  walls  of  which  were  exceedingly 
thickened,  while  its  lining  membrane  was  destroyed  by  ulcera- 
tion, and  numerous  warty  growths  or  granulations  beset  its  surface. 

In  this,  and  in  other  cases,  it  is  no  doubt  not  to  the  tubercular 
deposit  alone,  but  rather  to  the  consequent  pyelitis  and  cystitis 
that  the  patient's  intense  sufferings  are  due.  "What  it  concerns 
us  most  to  bear  in  mind  is,  that  inflammation  of  the  kidneys  and 
of  the  bladder,  may  occur  as  secondai-y  to  tubercular  deposit, 
when  yet  no  other  symptom  of  tuberculosis  i%  present,  and 
further,  that  such  a  disease  may  run  its  course  to  a  fatal  issue 
without  phthisis  supervening,  even  without  any  deposit  of  tu- 
bercle in  the  lungs  or  elsewhere  than  in  the  diseased  organs  and 
the  absorbent  glands  in  their  immediate  vicinity. 

One  other  class  of  cases  there  is,  characterized  like  the  preced- 
ing by  great  irritability  of  the  bladder,  but  more  chronic  in  their 
course,  and  tending  less  certainly  to  a  fatal  issue,  though  as  little 
amenable  to  treatment.  Their  symptoms  come  on  in  early  adult 
age,  and  occur  independently  of  pregnancy,  marriage,  or  of  any 
disorder  of  the  uterine  functions,  while  the  changes  which  the 
urine  itself  presents  are  not  very  remarkable.  It  is  neither  laden 
with  pus,  nor  does  it  abound  in  phosphatic  dei30sits;  its  quantity 
usuall}^  falls  a  little  below  the  average,  but  its  specific  gravity 
seldom  much  exceeds  1020°,  occasionally  falls  below  it;  it  is 
usually  nearly  neutral,  slightly  turbid,  containing  a  little  excess 
of  phosphates;  sometimes  also  crystals  of  the  oxalate  of  lime  may 
be  discovered  in  it,  and  now  and  then  a  little  albumen,  though  its 
presence  is  by  no  means  constant. 

The  history  of  these  cases  is  usually  very  obscure,  and  often 
presents  nothing  more  definite  than  the  causeless  occurrence  of 
frequent  desire  to  pass  water,  attended  hy  dull  pain  in  the  loins, 
extending  to  the  hypogastrium.      These  symptoms  come  on  so 


INFLAMMATION    OF    THE    BLADDER.  489 

gradually,  that  the  patient  can  scarcely  tell  the  date  of  their  com- 
mencement, but  knows  only  that  for  some  two  or  three  years  or 
more,  a  source  of  discomfort  from  which  she  used  to  be  free,  has 
been  by  degrees  growing  ui)on  her.  The  general  health  often 
continues  comparatively  undisturbed,  even  after  the  irritability 
of  the  bladder  has  become  very  troublesome,  while  the  symptoms 
of  constitutional  disorder  which  do  at  length  appear,  are  commoidy 
of  a  very  vague  and  ill-defined  character,  such  as  loss  of  apjietite, 
loss  of  strength,  and  general  gastro-intestinal  disorder,  with  a 
tongue  thinly  coated  with  yellow  fur,  and  not  cleaning  under  any 
modification  of  treatment.  My  impression  is,  that  these  are  cases 
of  a  chronic  form  of  nephritis,  and  that  when  tliey  endanger  life, 
it  is  by  the  extension  of  the  mischief  to  the  lining  membrane  of 
the  kidneys,  and  by  the  supervention  of  pyelitis,  with  that  chronic 
inflammation  of  tlie  bladder  itself  with  which  it  is  usually  asso- 
ciated. So  long  as  tliis  complication  is  absent,  the  disease  shows 
little  disposition  to  increase,  wdiile  there  are  long  pauses  in  its 
course,  though  never  a  complete  subsidence  of  all  the  symptoms, 
the  backache  disappearing  sooner  than  the  irritable  bladder,  while 
even  when  things  are  at  the  best,  a  trivial  cause,  and  especially  a 
slight  exposure  to  cold,  will  suflice  to  reproduce  all  the  ailments 
with  undiminished  intensity. 

Of  all  these  affections,  that  in  which  the  bladder  is  the  primary 
seat  of  the  mischief  is,  as  might  be  expected,  the  most  amenable 
to  treatment,  though,  even  then  the  course  of  the  diseasse  is  always 
slow,  and  recovery  often  but  imperfect.  Many  of  the  instances  of 
cystitis  after  delivery  are  traceable  to  neglect  of  the  very  obvious 
precaution  of  introducing  the  catheter  when  labor  is  at  all  pro- 
tracted, or  whenever  the  ])ressure  on  the  neck  of  the  bladder  has 
been  so  considerable  as  to  render  micturition  for  a  day  or  two 
painful  or  difficult.  Another  error  which  often  lays  the  founda- 
tion of  this  very  troublesome  complaint,  is  the  omitting  to  treat 
those  slighter  forms  of  cystitis  which  frequently  succeed  to  a  tedi- 
ous labor,  and  which,  though  they  in  many  instances  subside 
s]>ontaneously,  yet  rarely  disappear  so  speedily  or  so  eomidetely 
if  let  alone  as  if  a  few  leeches  are  applied  over  the  hypogastrium, 
and  the  uva  ursi,  combined  with  some  sedative,  is  administered, 
while  the  catheter  is  employed  regularly  to  prevent  any  retention 
of  urine.  These  precautions,  too,  are  perhaps  still  more  frequently 
overlooked,  though  scarcely  less  necessary  in  cases  where  periton- 
itis has  occurred,  or  where  inflammation  of  the  uterine  ajipcn- 
dages  has  taken  place  after  delivery  or  abortion,  or  even  in  the 
unimpregnated  state,  since  subacute  cystitis  is  fiir  from  bring  a 
rare  sequela  of  any  of  the  more  active  forms  of  abdominal  inflam- 
mation in  women  of  all  ages  and  in  all  circumstances. 

If  the  disease,  on  whatever  cause  it  depends,  has  not  been 
checked  at  its  ver}-  outset,  recovery  will  at  best  be  tedious.  Our 
prognosis  as  to  this  point  ma}'  in  general  be  deduced  with  tolerable 
accuracy  from  the  condition  of  the  urine,  the  presence  in  it  of  a 
large  deposit  of  the  phosphates  being  a  more  unfavorable  sign 


490 


trea'dment  of 


than  an  abundance  of  pns  or  of  mucus.  "Witli  reference  to  this, 
too,  it  may  not  be  out  of  place  to  observe  that  in  drawing  our  con- 
clusions from  the  gelatinization  of  the  urine  with  liquor  potasses, 
or  from  the  abundance  of  mucus  in  the  fluid,  we  ought  to  make 
sure  that  there  is  no  considerable  leucorrfioeal  or  purulent  dis- 
charge from  the  vagina,  since  its  unsuspected  admixture  with  the 
urine  has  sometimes  led  to  the  expression  of  a  far  more  un- 
favorable opinion  as  to  the  state  of  the  patient  than  was  really 
called  for. 

So  long  as  the  disease  retains  anything  of  an  acute  character 
local  depletion  will  still  be  useful,  and  the  application  of  six  or 
eiglit  leeches  to  the  hypogastrium,  two  or  three  times  repeated, 
will  be  of  more  service  than  the  employment  once  of  a  larger  num- 
ber. So  soon,  too,  as  the  tenderness  of  the  vagina  admits  of  the 
introduction  of  the  speculum  or  of  a  leech  tube,  the  relief  afforded 
by  drawing  blood,  from  the  anterior  vaginal  wall  will  generally 
be  found  to  be  very  remarkable.  The  patient  should  be  kept  in 
bed  ;  her  diet  should  consist  of  beef-tea,  larinaceous  substances, 
and  milk,  with  barley-water  and  the  Vichy  water  as  her  common 
drinks.  In  this  stage,  too,  I  know  of  no  better  medicine  than  the 
extract  and  decoction  of  uva  ursi.'  On  the  subsidence  of  the  more 
acute  symjitoms,  the  diet  may  be  improved,  and  the  hydrochloric 
acid  with  pareira,^  or  half-drachm  doses  of  the  diluted  phosphoric 
acid,  may  be  substituted  for  the  previous  prescription,  wliile  any- 
thing which  amends  the  patient's  general  health  will  probably  be 
of  service  in  lessening  the  irritability  of  her  bladder.  Wine  and 
tonics  are  often  of  service  when  the  acute  stage  of  the  ailment  is 
passed,  and  the  urine,  thongh  unhcaltliy  in  cliaracter,  is  secreted 
in  suflicient  quantity;  and  sometimes  quinine,  at  other  times 
chalybeate  preparations,  will  be  i'ound  to  be  most  useful.  The 
irritability  of  the  bladder  not  infrequently  continues  as  the  result 
of  mere  habit  after  the  disease  to  which  it  was  originally  due  has 
subsided.  Large  doses  of  the  tincture  of  the  sesquichloride  of  iron, 
as  fifteen  or  twenty  minims  throe  or  four  times  a  day,  frequently 
relieve  this  infirmity;  while  it  is  also  desirable  to  give  a  sixth  or 
a  fourth  of  a  grain  of  morphia  every  night  in  order  to  lessen  the 
incessant  desire  to  pass  water,  which  otherwise  would  deprive  the 
patient  of  sleep.  Something,  however,  will  still  always  remain  to 
be  accomplished  by  the  voluntary  efibrts  of  the  patient  to  over- 
come a  habit  which,  if  unchecked,  will  so  much  interfere  with  the 
comfort  of  her  future  life.  During  convalescence,  the  patient  can- 
not too  sedulously"  guard  against  catching  cold,  or  against  any 
disorder  of  her  menstrual  function,  each  return  of  which  will  long 


1  (No.  12.) 

R.  Extract!  Uva?  Ursi,      .  .  ^j 

Tiiict.  Hyoscyami,  .     .  .  ^iij 

Tinct.  Aurantii,        .     .  .  ."ij 

Decoct.  Uva?  Ursi,  ad  .  .  5VJ 
M.  ft.  mist.,  cujussumatcochl.  2  ampla 
4ta  quaque  hora. 


2  (No.  13.) 
R.  Extracti  Pareirae,  .     .  gr.  xlviij 
Acid.  Hydrochlor.  dil.,  tijj  xl 
Morphia^  Hydrochlor.,  gr.  ss. 
Decoc.  Pareirae,       .     .  ,^vj 
M.  ft.  mist.,  cujus  sumat  4tam  partem 
6ta  quaque  hora. 


CHRONIC    CYSTITIS.  491 

bring  with  it  some  revival  of  her  former  discomfort,  and  a  threat- 
ening, at  least,  of  the  rekindling  of  former  disease.  Lastly,  I  may 
add,  it  is  inexpedient  that  a  married  woman  should  return  to  her 
husband's  bed,  to  the  local  excitement  of  sexual  intercourse,  and 
to  the  risks  of  pregnancy,  until  her  recovery  is  well  established. 

Cystitis  is  unfortunately  less  often  met  with,  at  least  among  the 
poorer  class  of  patients,  in  the  subacute  form  than  in  one  de- 
cidedly chronic,  in  wliich,  in  addition  to  pus  and  the  phosphates, 
the  urine  contains  a  large  quantity  of  extremely  tenacious  mucus, 
is  intensely  alkaline,  and  of  a  higlily  ammoniacal  odor.  In  this 
condition,  in  spite  of  a  very  intense  degree  of  local  tenderness, 
and  of  very  frequent  desire  to  pass  water,  the  abstraction  of  blood 
must  not  be  resorted  to ;  for  it  weakens  the  patient's  general 
powers  without  alleviating  her  ailment.  A  first  step  towards  re- 
lieving her  sufferings  is  to  place  her  in  bed  ;  the  uniform  temjiera- 
ture  of  the  surface  being  thus  maintained,  prevents  any  sudden 
demand  being  made  on  the  function  of  the  kidneys,  while  the 
disposition  to  congestion  of  the  pelvic  viscera  is  much  lessened 
by  the  maintenance  of  the  horizontal  posture.  Throughout  the 
wdiole  course  of  one  of  these  cases,  opium  in  some  form  or  other 
is  the  remedy  on  which  our  greatest  dependence  must  be  placed, 
and  its  value  far  exceeds  that  of  any  medicine  supposed  to  exert 
a  sp<'cific  influence  on  the  bladder.  Of  these  medicines,  two  of 
the  most  useful,  the  uva  ursi  and  the  pareira,  liave  already  heen 
alluded  to.  "When  these  remedies  fail  in  the  foiVns  which  1  have 
already  suggested,  I  have  seen  benefit  result  from  the  combina- 
tion .of  the  pareira  either  with  small  doses  of  copaiba  or  with  the 
benzoic  acid.  Sometimes,  too,  especially  where  the  secretion  of 
urine  is  scanty,  the  benzoin  alone  has  proved  serviceahle,  though 
a  not  infrequent  drawback  from  au}^  of  these  medicines  is  that 
they  nauseate  the  stomach  ;  and  the  alleviation  of  local  suffering 
is  then  too  dearly  purchased  at  the  expense  of  the  patient's  general 
health. 

I  have  on  several  occasions  made  trial  of  injections  into  the 
bladder  in  cases  where  tlie  condition  of  the  urine  was  vavy  un- 
healthy, and  where  it  contained  a  large  quantity  of  ropy  mucus. 
For  this  purpose  I  have,  in  accordance  Avith  Sir  ]>.  Brodie's  sugges- 
tion, emi)loyed  the  decoction  of  popjdes,  to  which  I  have  but  very 
rarely  added  a  few  drops  of  dilute  nitric  acid.  The  instances,  how- 
ever, in  which  this  proceeding  was  at  all  tolerated  were  quite 
exceptional,  and  almost  always  such  severe  and  such  abiding  j)ain 
was  excited  as  to  comi»el  me  to  desist  from  a  repetition  of  the  ex- 
periment. Even  when  borne  for  two  or  three  times,  and  giving 
an  earnest  of  effecting  some  lasting  good  by  the  improvement 
W'hich  it  wrought  in  the  state  of  the  urine,  pain  has  seldom  failed 
to  come  on,  and  to  preclude  the  continued  employment  of  the 
measure.  One  reason  of  this  failure  (for  I  am  not  aware  of  any 
want  of  care  either  in  the  selection  of  the  cases  or  in  tlie  ai>p]ica- 
tion  of  the  remedy)  may  perhaps  have  been  that  the  persistence 
of  chronic  cystitis  iu  the  feniale  subject  for  any  considerable  time, 


492  VESICO-VAGINAL    FISTULA. 

generally,  if  not  invariably,  occasions  irritation  of  the  kidneys, 
and  a  sort  of  subacute  pyelitis.  There  seems  also  to  be  a  great 
tendency  for  the  mischief  in  these  cases  to  terminate  in  ulcera- 
tion of  the  mucous  membrane  of  the  bladder,  and  not  to  stop 
short  with  the  induction  of  that  thickening  which  is  so  common 
in  the  male  subject. 

One  other  proceeding  which  I  have  now  and  then  resorted  to  in 
cases  of  chronic  cystitis  with  much  irritability  of  the  bladder,  has 
been  the  introduction  of  a  seton  just  above  the  symphysis  pubis. 
I  have  observed  decided  benefit  from  it,  especially  in  those  cases 
where  the  irritaljility  of  the  bladder  was  out  of  proportion  to  the 
amount  of  obvious  disease;  tliough  from  its  nature  this  remedy  is 
one  to  which  we  cannot  very  often  have  recourse. 

It  would  perhaps  scarcely  be  right  to  take  leave  of  the  subject 
of  inflammation  of  the  bladder  Avithout  a  word  or  two  concerning 
those  sad  cases  in  which  vaginitis  following  delivery  terminates 
in  the  death  of  the  tissues,  and  in  the  formation  of  a  fixtu/ous 
communication  betiveen  the  bladder  and  vagina.  There  can  be  no 
doubt  but  that  in  the  great  majority  of  instances  this  accident  is 
due  to  the  delay  of  instrumental  interference  in  tedious  labor, 
coupled  with  the  omission  to  use  the  catheter.  It  is  extra- 
ordinary how  often  this  latter  simple  precaution  is  neglected, 
how  often  the  statement  of  the  patient  or  of  her  nurse  is  accepted 
as  conclusive  other  having  emptied  her  bladder;  while  the  practi- 
tioner, conscious  perhaps  of  his  own  inexpertness  in  performing 
this  little  operation,  is  only  too  ready  to  frame  an  excuse  to  his 
own  mind  for  not  attempting  to  do  that  which  he  knows  he  should 
do  but  awkwardly,  and  fears  that  he  might  possibly  fail  to  do  at 
all.  To  this  neglect  of  the  catheter,  and  to  the  omission  to  inter- 
fere instrumentally  as  early  as  is  necessary,  is  the  occurrence  of 
vesico-vaginal  fistula  to  be  attributed  far  oftener  than  to  any  direct 
injury  inflicted  by  the  instruments  themselves.  After  labor  is  over, 
too,  the  same  neglect  to  keep  the  bladder  empty  not  only  adds  to 
the  patient's  distress,  but  greatly  aggravates  the  perhaps  inevitable 
cystitis,  and  renders  the  ease  to  a  great  degree  unfit  for  any  attempt 
at  cure  by  means  of  a  plastic  operation. 

Wherever  from  the  protraction  of  labor,  and  from  the  long  stay 
of  the  head  in  the  pelvic  cavity,  there  is  any  reason  to  fear  the 
occurrence  of  inflammation  of  the  vagina,  its  possible  issue  in 
sloughing  and  in  the  formation  of  a  fistula  must  always  be  borne 
in  mind,  and  attention  must  be  closely  directed  to  the  local  con- 
dition of  the  patient  as  well  as  to  her  general  symptoms.  The 
bladder  must  be  regularly  emptied  by  the  elastic  catheter  every 
six  hours,  a  warm  poultice  must  be  constantly  applied  to  the  hypo- 
gastrium,  and  poppy  fomentations  to  the  vulva;  while  the  vagina 
must  be  carefully  syringed  twice  a  day  with  lukewarm  water,  and 
local  leeching  must  be  at  once  employed  on  the  first  onset  of 
symptoms  of  cystitis.  The  state  of  the  parts  must  not  be  judged 
of  from  hearsay,  but  must  be  inspected  every  day ;  a  precaution 
which,  though  especially  necessary  when  any  laceration  of  the  pe- 


MEANS    OF    PREVENTING    IT.  493 

rinenm  has  taken  place,  is  yet  in  these  cases  always  worth  taking, 
since  the  appearance  of  the  vulva  furnishes  no  bad  index  to  the 
general  state  of  the  vagina.  If  the  secretion  from  the  vagina  as- 
sumes an  unhealthy  character,  and  if  shreds  of  mucous  membrane 
appear  in  it,  we  may  be  sure  that  sloughing  has  taken  ])lace,  and 
though  the  sloughing  may  be  superficial,  yet  of  this  we  cannot  be 
certain,  while  contraction  of  the  canal,  and  the  formation  of  cica- 
trices are  its  almost  inevitable  results.  The  soothing  injection 
previously  used  must  now  be  changed  for  otliers  of  a  more  stimu- 
lating kind,  while,  when  the  parts  begin  to  heal,  it  will  be  expedient 
to  introduce  a  large  gum-elastic  bougie  into  the  vagina,  and  to 
allow  it  to  remain  for  some  hours  every  day,  in  order  to  pi-event 
adhesions  forming  between  the  op})Osite  surfaces  of  the  vtiginaby 
which  the  orifice  of  the  uterus  is  sometimes  almost  com[)letely 
closed,  or  the  vaginal  canal  itself  is  divided  into  two  chambers, 
into  the  upper  of  which  the  uterus  opens.  Nor  indeed  are  these 
the  only  possible  consequences  of  sloughing  of  the  vagina,  but  in 
proportion  to  the  extent  of  the  mischief  the  vagina  is  shortened; 
the  edges  of  any  fistula  are  permanently  kept  asunder,  the  space 
between  the  opening  and  the  neck  of  the  womb  is  diminished, 
while  the  cicatrix  tissue  on  wdiich  the  operator  has  to  depend  for 
the  closure  of  the  apertui'C  is  endowed  with  far  feebler  vitality  than 
the  unaltered  structures  of  which,  if  the  mischief  has  been  cir- 
cumscribed, he  may  hope  to  avail  liimself. 

Su[)posing  all  these  points  to  have  received  due  attention,  the 
next  question  that  suggests  itself  concerns  the  period  after  labor 
at  which  any  operation  for  the  cure  of  the  fistula  should  be  at- 
tempted. Now,  I  believe  that  nothing  should  be  done  within  the 
first  three  montlis  after  delivery  at  the  soonest,  for  the  suscepti- 
bility to  inflammation  is  greater  in  the  woman  who  has  recently 
miscan-ied  or  given  birth  to  a  child  than  in  another,  while  not  only 
are  all  plastic  operations  about  the  sexual  organs  attended  by  some 
hazard,  but  a  degree  of  local  inflammation  quite  iiuidequate  to 
cause  danger  to  the  patient,  may  yet  more  than  suffice  to  destroy 
the  promise  of  the  most  dexterous  operation.  Another  reason,  too, 
for  some  delay  is  that  wnthin  certain  limits  a  fistulous  opening  is 
likely  to  contract;  and  it  is  well  to  obtain  the  full  amount  of  im- 
provement which  nature  can  efi'ect  before  having  recoui;se  to  any 
surgical  proceeding.  Besides  this,  too,  it  is  of  the  greatest  im- 
portance that  a  person  should  be  in  the  best  possible  health  before 
the  operation  is  undertaken,  and  no  delay  can  be  regretted  which 
attbrds  the  opportunity  for  the  amendment  of  her  general  condi- 
tion, and  the  improvement  of  the  state  of  her  urine.  The  two 
generally  keep  pace  with  each  other,  and  my  own  impression  is, 
that  to  operate  at  a  time  when  the  health  is  feeble,  and  the  urine 
abounds  in  phosphatic  deposits,  is  completely  to  throw  away  all 
chance  of  benefiting  our  patient.  If  the  aperture  in  the  bladder 
is  comparatively  small,  so  that  urine  can  be  retained  for  an  hour 
or  so,  in  certain  positions  of  the  body,  delay  may  be  allowed  a 
month  or  two  longer,  provided  that  the  bladder  tolerate  the  fre- 


494  INTESTINO-VESICAL    FISTULA. 

queiit  introduction  of  the  catheter ;  an  operation  which  the  patient 
will  soon  learn  to  perform  for  herself.  I  am  not,  however,  disposed 
to  recommend  that  a  catheter  be  kept  constantly  in  the  bladder; 
for  a  few  days  are  generally  the  utmost  limit  during  which  the 
patient  can  bear  it;  the  bladder  then  becoming  irritated  by  its 
presence,  so  as  to  compel  the  removal  of  the  instrument.  Still 
less  would  T  advocate  the  use  of  the  plug,  or  of  any  mechanical 
device  for  restraining  the  outflow  of  the  urine.  All  such  contri- 
vances irritate,  and  are  likely  to  interfere  with  that  healthy  con- 
dition of  the  parts  which  it  is  so  essential  to  maintain.  In  all 
instances,  therefore,  where  the  aperture  is  large,  and  where  no 
urine  is  retained,  delay  continued  after  the  etiects  of  the  puerperal 
processes  have  subsided,  answers  nouseful  end ;  while  when  wait- 
ing for  this  we  must  content  ourselves  with  the  daily  use  of  the 
tepid  hip-bath,  with  the  injection  of  warm  water  into  the  vagina, 
and  with  the  most  sedulous  al)lution  and  scrupulous  cleanliness, 
as  means  of  preventing  the  irritation  of  the  parts  by  the  perpetual 
escape  of  the  urine. 

It  would  be  out  of  my  province  to  go  into  detail  concerning 
the  operation  for  the  closure  of  vesico-vaginal  fistula.  Two  jjointa 
only  I  may  just  refer  to.  One  concerns  the  utility  of  the  galvanic 
cautery,  especially  in  the  more  chronic  fistuhe,  in  those  of  small 
size,  or  whose  dimensions  have  been  reduced  by  other  operative 
proceedings.  By  its  frequent  application  in  one  case,  my  col- 
league, Mr.  Paget,  effected  a  complete  cure.  The  other  point  has 
reference  to  the  great  merit  both  of  the  mode  of  operating  adopted 
by  Dr.  Sims,  of  Alabama,'  and  also  of  his  curved  catheter,  which 
often  remains  in  the  bladder  without  any  trouble  or  atiy  adapta- 
tion of  her  posture  on  the  part  of  the  patient,  and  answei-s  the 
purpose  of  preventing  all  escape  of  urine  by  the  wound  far  more 
effectually  than  a  catheter  of  the  ordinary  form.  Even  this,  how- 
ever, irritates  in  a  few  days,  and  requiies  withdrawal  earlier  than 
is  quite  satisfactory;  an  evil  which  perhaps  its  construction  of 
some  very  light  material  might  in  some  measure  obviate. 

It  is  not  necessary  to  say  much  about  that  rare  accident  mtesfino- 
vesical  fstula  ;  for  the  circumstances  in  which  it  occurs  have  no 
necessary  connection  with  the  sexual  ailments  of  women.  I  have 
met  with  it  but  thrice.  In  the  first  case,  it  was  associated  with 
malignant  disease  of  the  uterus;  and  dysuria  and  painful  defeca- 
tion had  existed  for  between  two  and  three  years,  their  occurrence 
being  coincident  with  the  appearance  of  an  indurated  tumor  in 
the  left  iliac  and  inguinal  regions;  and  the  escape  of  faecal  matter 
with  the  urine  had  taken  place  for  four  months  previous  to  the 
patient's  admission  into  the  hospital.  In  the  second  case,  the  mis- 
chief succeeded  to  ulceration  of  the  intestines  during  fever  nine 

1  American  Journal  of  Med.  Sciences,  Jan.,  1852,  and  a  pamphlet  with  the  title, 
Silver  Sidures  in  Sui-gery,  New  York,  1858.  His  earliest  and  his  latest  suy;<:;csti()ns 
present,  indeed,  many  points  of  difference,  but  all  seem  tending  to  simplify  the 
means  of  relieving  this  most  grievous  infirmity,  and  to  increase  the  chances  of  its 
cure. 


FUNGOUS  TUMORS  OF  BLADDER.  495 

weeks  before,  which  had  issued  in  the  formation  of  a  pouch  com- 
municating above  witli  the  sigmoid  flexure  of  the  colon,  and  below 
with  both  rectum  and  bladder.  This  patient  died  in  the  course 
of  a  few  weeks,  but  less  in  consequence  of  the  local  disease  than 
of  the  progressive  increase  of  the  exhaustion  which  the  fever  had 
occasioned.  The  third  case  was  that  of  a  young  lady  in  whom 
8U[tpression  of  the  menses  from  cold  was  succeeded  b}-  inflamma- 
tion, which  involved  among  other  parts  the  uterine  appendages 
on  the  right  side,  where  a  distinct  tumor  formed.  This  tumor,  at 
first  quite  solid,  afterwards  grew  softer,  and  then  diminished  in 
size.  Its  diminution  was  not  attended  by  any  very  marked  dis- 
charge of  pus,  but  about  the  same  time  purulent  and  fecal  matter 
began  to  appear  in  the  urine,"  and  continued  to  be  intermixed  with 
it  for  three  weeks  when  she  first  came  under  my  notice.  In  this 
case,  as  in  the  other  two,  the  sensitiveness  of  the  bladder  was  so 
great  that  all  attempts  at  syringing  it  with  tepid  water  were  of 
necessity  discontinued ;  but  great  relief  followed  the  use  of  very 
simple  means,  such  as  the  employment  of  the  uva  ursi,  of  hydro- 
chloric acid  and  the  pareira,  and  the  administration  of  opium  or 
morphia,  to  mitigate  sufl'ering  and  to  relieve  tlie  irritability  of  the 
bladder.  In  the  case  of  the  young  lady,  too,  concerning  whom 
alone  was  there  much  room  for  hopefulness,  the  fistulous  com- 
nmnication  became  closed  in  the  course  of  two  months,  and  after 
the  lapse  of  a  year  I  saw  her  in  perfect  health  ;  slightly  diminished 
mobility  of  the  uterus  being  the  only  remaining  evidence  of  the 
serious  bygone  mischief 

I  am  not  aware  of  having  ever  met  with  those  soft  fungous 
tumors,  or  polypoid  excrescences  from  the  bladder,  whose  true 
relation  to  malignant  disease  seems  to  be  still  undetermined.  It 
is,  indeed,  possible  that  in  some  of  the  cases  of  dysuria  which 
have  come  under  my  notice  the  symptoms  may  have  arisen  from 
this  cause;  but  there  is  no  sign  actually  pathognomonic  of  their 
existence,  and  though  in  all  obscure  cases  I  am  accustomed  to  have 
recourse  to  the  microscope  for  help,  I  have  never  yet  succeeded 
by  its  means  in  the  diagnosis  of  any  outgrowth  from  the  bladder.' 
In  one  respect,  indeed,  these  growths  conform  to  the  same  rule 
as  decided  malignant  disease  of  the  bladder,  for  while  not  very 
conmion  in  either  sex,  they  are  yet  infinitely  rarer  in  the  female 
than  in  the  male.  Often  cases  of  fungoid  disease  of  the  bladder 
recorded  in  the  Transactions  of  the  Pathological  Socictg,^  there 
were  but  three  in  which  the  subject  was  a  female,  and  in  like 
manner  of  the  seven  cases  of  carcinomatous  disease  of  the  bladder 

1  Tlio  general  opinion,  and  that  adopted  hy  Kokitanskj-,  op.  cit.,  vol.  iii,  p.  4(50, 
is  tliat  these  outgrowths  all  belong  to  the  class  of  malignant  diseases.  An  opposite 
view  is,  however,  maintained  by  .Mr.  Sibley,  in  Traxsdction.i  of  Path.  Sucirii/,  vol. 
vii,  pp.  2.j()  and  214,  based  on  very  careful  microscopic  observations.  "Gross,  On 
the  Vriiutry  Ortjanfi,  2d  ed.,  l*hiladcl|)liia,  1H.')0,  p.  324,  in  his  notice  of  these  out- 
growtlis.  assumes  their  non-mulignant  character. 

2  Tile  three  eases  in  the  female  subject  are  reported  in  vol.  v,  p.  200,  vol.  vii, 
p.  2i')(),  and  vol.  xi,  p.  l.')3;  the  otiiers  in  vol  ii,  pp.  8o  and  237,  vol.  iii,  pp.  126 
and  127,  vol.  v,  p.  201,  vol.  vi,  p.  258,  and  vol.  viii,  p.  2(j2. 


496  MALIGNANT    DISEASE 

on  which  M.  Lebert^  founds  his  observations,  six  occurred  in  the 
male  subject. 

In  the  only  case  of  primary  malignant  disease  of  the  bladder 
that  has  ever  come  under  my  notice,  the  patient  was  a  widow 
woman,  sixty-two  years  of  age,  who  had  suffered  for  a  year  pre- 
viously from  pain  in  the  region  of  the  bladder,  aggravated  after 
passing  water,  the  calls  to  which  became  more  frequent  than  natu- 
ral, while  at  the  same  time  her  urine  grew  turbid,  and  deposited  a 
thick  sediment.  Blood  now  frequently  appeared  in  her  urine, 
sometimes  in  small  quantities,  sometimes  in  clots,  and  about 
three  months  before  I  saw  her  she  lost  a  large  quantity  at  once. 
She  had  of  late  suffered  from  pain  in  the  back,  and  for  two  months 
the  urine  had  been  always  thick  with  a  ropy  sediment.  Ko  treat- 
ment had  been  adopted  till  three  weeks  before  her  admission  into 
the  hospital,  when  the  patient  applied  to  a  surgeon,  who  intro- 
duced a  catheter,  an  operation  followed  by  considerable  hemor- 
rhage, which  lasted  for  several  days,  though  it  was  eventually 
sujjpressed  by  gallic  acid. 

On  being  received  into  the  hospital  the  patient's  appearance  was 
healthy,  her  pulse  was  80,  and  soft,  her  tongue  slightly  coated,  her 
bowels  were  regular.  Xo  tumor  was  percei)tible  in  the  abdomen, 
but  iirm  pressure  immediately  over  the  pubcs  caused  some  pain. 
The  uterus  was  high  up,  small,  its  tissue  soft  and  perfectly  healthy. 
In  front  of  the  uterus,  pushing  it  into  the  posterior  half  of  the  pel- 
vis, was  a  firm,  somewhat  irregular  growth,  reaching  from  the 
anterior  half  of  the  pelvis  in  the  situation  of  the  bladder,  appar- 
entl}^  extending  round  that  organ  on  either  side,  but  much  more 
on  the  right.  This  growth  was  perfectly  immovable;  it  seemed 
to  be  connected  with  the  pelvic  walls;  was  somewhat  tender  on 
pressure.  It  was  of  such  size  as  to  occupy  the  whole  anterior 
half  of  the  pelvic  brim,  though  not  dipping  down  considerably 
into  the  pelvic  cavity. 

The  urine  was  pale,  alkaline,  depositing  ropy  mucus,  and 
under  the  microscope  crystals  of  the  triple  phosphate  and  cells  of 
nucleated  epithelium  were  perceptible. 

The  patient  derived  considerable  comfort  from  treatment  dur- 
ing ten  days'  stay  in  the  hos[)ital;  Ijut,  returning  home  at  the  end 
of  that  time,  and  indulging  in  the  intemperate  habits  to  which 
she  was  addicted,  she  fell  and  injured  her  face — an  accident  that 
was  followed  by  fatal  erysipelas  on  the  twelfth  day  after  she  left 
the  hospital.  The  uterus  and  vagina  were  found  on  examination 
after  death  to  be  perfectly  healtliy ;  but  the  whole  posterior  half 
of  the  bladder  was  occupied  by  a  medullary  growth,  with  an  ir- 
I'egular  surfiice,  which  projected  into  the  cavity  of  the  organ,  its 
substance  being  in  part  firm,  in  part  almost  semifluid.  The  an- 
terior half  of  the  bladder  was  quite  healthy,  as  also  was  the  sub- 
stance of  both  kidneys,  except  that  the  right  ureter  being  involved 
in  the  diseased  mass  was  dilated  to  three  or  four  times  its  natural 

1  Oj).  cit,  p.  876. 


OF    THE    BLADDER.  497 

size,  and  the  infunclibulum  of  the  right  kicluey  was  enormously 
enlarged. 

As  far  as  it  went,  this  patient's  history  was  exactly  tliat  of 
malignant  disease  of  the  hhidder,  and  had  not  her  life  been  pre- 
maturely cut  short,  the  affection  would  no  doubt  have  run  its 
usual  course.  Hemorrhage  would  have  returned  again  and  again, 
and  would  have  weakened  the  patient  more  and  more ;  the  in- 
creased growth  would  have  produced  increased  difficulty  in  mic- 
turition, while  the  advance  of  the  malignant  disease  would  have 
been  associated  with  the  further  development  of  the  cancerous 
cachexia;  till,  under  these  combined  causes,  death  would  at  length 
have  taken  place  in  circumstances  far  more  painful  than  those  by 
which  it  was  actually  attended. 

As  in  this  case,  so  I  believe  in  most  instances  of  primary  malig- 
nant disease  of  the  bladder,  there  is  but  little  tendency  to  the  per- 
foration of  its  walls  and  the  extension  of  the  disease  into  the 
vagina.  The  constant  dribbling  away  of  the  urine  which  some- 
times attends  the  more  advanced  stages  of  this  disease  by  no 
means  necessarily  indicates  the  existence  of  any  communication 
between  the  bladder  and  vagina;  but  is  due  in  many  instances 
partly  to  the  encroachment  of  the  evil  on  the  cavity  of  the  blad- 
der, partly  to  its  walls  having  been  rendered  unyielding  by  dis- 
ease, and  especially  to  the  infiltration  of  the  tissue  of  the  neck  of 
the  bladder  with  carcinomatous  deposit.  The  observation  of 
Kiwisch'  is  also  worth  repeating  here,  "that  the  occurrence  of 
incontinence  of  urine  in  the  course  of  cancer  of  the  uterus  is  not 
to  be  regarded  as  a  certain  evidence  of  the  occurrence  of  perfora- 
tion of  the  bladder,  for  this  symptom  is  frequently  only  the  con- 
sequence of  carcinomatous  infiltration  of  the  neck  of  the  bladder, 
and  especially  of  that  part  corresponding  to  the  spliincter,  by 
which  it  is  hindered  in  the  performance  of  its  functions,  and  thus, 
no  longer  closing  the  ostium  vesicae,  admits  of  the  constant  escape 
of  the  urine." 

Though  the  diagnosis  of  fungoid  outgrowths  from  the  bladder 
may  be  ol)scure,  yet  the  ordinary  form  of  malignant  disease  of  the 
organ  appears  to  be  too  well  marked  to  leave  much  room  ibr  un- 
certaint3\  The  ceaseless  pain  and  difficulty  in  micturition,  coupled 
with  the  frequent  desire  to  pass  water,  the  occasional  appearance 
of  blood  in  the  urine,  sometimes  in  considerable  quantity,  and  in 
the  form  of  clots,  while  the  secretion  is  habitually  alkaline,  un- 
healthy, and  deposits  a  sediment,  are  of  tliemselves  strong  evi- 
dences of  the  nature  of  the  case,  though  scarcely  conclusive  unless 
associated  with  a  firm,  immovable  tumor  in  front  of  the  uterus. 
In  the  absence  of  the  evidence  obtained  by  vaginal  examination, 
the  extreme  rarity  of  primary  cancerous  disease  of  the  bladder 
always  renders  it  the  more  probable  supposition  that  the  kidneys 
are  the  seat  of  the  mischief. 

There  is  no  treatment  specially  applicable  to  malignant  disease 

1  Oji.  cit.,  vol.  iii,  p.  308. 
32 


498  CONGESTION    OF    THE    URETHRA, 

of  the  bladder.  The  indications  to  be  followed  are  very  obvions, 
and  within  certain  limits  and  for  a  certain  time  their  fulfihnent 
would  not  appear  to  be  difficult.  To  relieve  pain  by  opiates,  to 
render  the  urine  less  irritating  by  the  mineral  acids,  the  pareira, 
and  those  other  remedies  to  which  reference  has  been  made  in  the 
earlier  part  of  this  lecture,  to  keep  the  patient  in  bed,  and  thus  to 
equalize  as  far  as  possible  through  the  whole  twenty-four  hours 
the  demands  upon  the  functions  of  the  kidneys,  and  to  maintain 
the  general  health  by  good  diet,  and  by  the  moderate  use  of  stim- 
ulants, are  the  objects  to  aim  at.  When  once  the  nature  of  the 
disease  has  been  ascertained,  the  introduction  of  instruments  into 
the  bladder  must  be  carefully  avoided;  while,  if  it  should  become 
necessary  to  draw  off  the  urine,  an  elastic  catheter  without  its  stilet 
must  be  employed  with  all  possiljle  gentleness.  It  is,  however,  I 
believe,  but  seldom  in  the  female  subject  that  this  disease  pro- 
duces actual  retention  of  urine,  though  I  remember  a  patient 
many  years  ago  in  the  Middlesex  IIo8[)ital,  in  whom  tlic  urethra 
became  im[)li('ated  in  the  extension  of  the  growth,  so  that  it  be- 
came eventually  necessary  to  tap  the  bladder  above  the  pubes,  an 
operation  which  she  survived  only  a  very  few  days. 


LECTURE    XXXII. 

DISEASES  OF  THE  URETHRA  AND  VAGINA. 

Diseases  of  the  Urethra.     Congestion  of  the  urethra,  most  troublesome  as  a 

chronic  ailment;  its  symptoms  and  treatment. 
Vascular  tumors  of  urethral  orifice,  their  .seat,  nature,  symptoms,  and  treatment. 
Ulceration  of  urethra  ;  doubts  as  to  its  syphilitic  nature. 
Diseases  of  the  Vagina.     Acute  vaginitis;  character  of  the  discharge  which 

attends  it  as  distinguished  from  uterine  leucorriuiia:  its  treatment. 
Chronic  vaginitis.     Granular  vaginitis,  its  real  nature. 
Cysts  of  vagina. 

Fibrous  and  libro-cellular  tumors  of  vagina. 
Cancer  of  vagina. 

From  tbe  study  of  the  affections  of  the  bladder,  we  pass  next 
by  a  natural  transition  to  the  examination  of  those  incidental  to 
the  female  urethra^  a  class  of  ailments  which,  though  compara- 
tively trivial,  are  often  attended  by  very  serious  discomfort,  and 
are  by  no  means  easy  of  cure. 

Of  these  ailments,  one  of  by  no  means  unusual  occurrence  is  a 
state  of  undue  congestion  of  the  urethra,  which  sometimes  presents 
itself  in  an  acute  form,  at  other  times  has  a  chronic  character. 
In  the  former  case,  it  very  generally  accompanies  a  similar  condi- 
tion of  the  pelvic  viscera,  and  hence  is  chiefly  observed  either  in 
newly-married  women,  or  at  the  commencement  of  a  menstrual 
period,  or  is  experienced  during  the  first  few  weeks  of  pregnancy. 
It  is  then  attended  by  a  sense  of  itching  and  irritation  about  the 


AND    THICKENING    OF    ITS    WALLS.  499 

urethral  orifice,  wliicli  is  redder  than  natural,  slightly  swollen,  and 
tender  to  the  touch,  while  micturition  is  accompanied  by  a  scald- 
ing or  cutting  sensation,  the  discomfort  of  which  induces  the  pa- 
tient to  retain  her  urine  longer  than  usual. 

This,  however,  is  a  temporary  discomfort,  lasting  for  the  most 
part  no  longer  than  the  cause  which  produced  it,  though  its  fre- 
quent recurrence  may  no  doubt  issue  in  the  chronic  form  of  the 
ailment,  which  constitutes  an  abiding  source  of  annoyance  difficult 
to  remove  and  very  apt  to  recur.  Tljis  chronic  congestion  of  the 
urethra  comes  on  with  no  apparent  exciting  cause  in  women  who 
have  given  birth  to  many  children,  the  interruption  to  the  free 
circulation  in  the  pelvic  vessels  having  no  doubt  produced  it,  for 
which  reason.it  also  sometimes  follows  on  attacks  of  uterine  in- 
flammation, or  of  pelvic  abscess,  or  comes  on  during  the  growth 
of  a  uterine  or  ovarian  tumor.  It  adds  also  in  other  instances 
to  the  distress  produced  by  affections  of  the  bladder,  or  is  asso- 
ciated with  disease  of  the  kidney,  and  with  morbid  states  of  the 
urinary  secretion.  In  this  form  of  the  disease  there  is  very  cou- 
sidorabic  thickening  of  the  whole  canal,  which  may  be  traced  as 
a  firm  cord  as  thick  as  the  finger,  or  even  thicker,  running  under 
the  symphysis  pubis,  somewhat  tender  upon  pressure ;  while  if 
the  nymphae  are  separated,  it  may  be  seen  as  a  large  swelling  at 
the  upper  part  of  the  entrance  of  the  vulva,  looking  almost  like  a 
distinct  tumor  growing  from  the  anterior  vaginal  wall.*  The 
long-standing  congestion  has  here  been  followed,  as  it  is  else- 
where, by  overgrowth  of  the  part,  by  hypertrophy  of  the  cellular 
tissue  of  the  urethra,  and  hence,  though  the  swelling  may  vary  in 
size,  and  the  symptoms  which  it  produces  may  admit  of  very  great 
alleviation,  yet  tlioy  never  entirely  disappear,  and  very  slight 
causes  suffice  to  reproduce  them. 

These  symptoms  consist  in  a  sense  of  fulness  and  aching,  ac- 
companied by  frequent  desire  to  pass  water,  which  is  scarcely  at 
all  relieved  by  the  act  of  micturition.  The  erect  posture  aggra- 
vates these  discomforts,  as  do  sexual  intercourse  and  the  approach 
of  the  menstrual  period,  while  relief  is  obtained  by  rest  and  the 
recumbent  posture.  The  natural  tendency  of  the  affection  is,  as 
can  be  readily  understood,  to  grow  more  and  more  troublesome 
under  the  influence  of  those  causes  which  first  produced  it ;  at- 
tacks of  an  acute  kind  coming  on  every  now  and  then,  during 
which  the  urethra  becomes  more  swollen  and  more  tender,  and 
the  pain  in  micturition  extremely  severe.  In  one  instance  I  saw 
an  attack  of  this  kind  issue  in  the  occurrence  of  suppuration  in 
the  cellular  tissue  around  the  urethra,  and  on  puncturing  the  ab- 
scess quite  an  ounce  of  pus  escaped;  but  on  all  other  occasions 
these  attacks  have  subsided  almost  spontaneously,  and  without 
leading  to  any  such  result. 

There  is  no  other  condition  with  which,  as  far  as  I  know,  this 

1  This  condition  was  first  described  by  Sir  C.  Clarke,  Diseases  of  Women.  yo\.  i, 
p.  309. 


500  VASCULAR    EXCRESCENCES 

state  of  the  urethra  can  be  confounded.  The  only  caution,  there- 
fore, which  seems  to  me  necessary  as  to  this  point  concerns  the 
occasional  dependence  of  this  thickened  state  of  the  urethra  upon 
the  presence  of  one  of  those  small  vascular  excrescences  of  its 
mucous  membrane,  which  though  usually  seated  at  its  orifice,  are 
yet  sometimes  so  far  within  the  lips  of  the  canal  as  to  escape  a 
superficial  examination. 

The  acute  form  of  urethral  congestion  is  generally  so  brief  in 
its  duration  as  scarcely  to  call  for  treatment.  A  tepid  hip-bath, 
the  temporar}'  discontinuance  of  sexual  intercourse,  if  the  symp- 
toms have  succeeded  to  marriage,  the  avoidance  of  all  stimulants, 
mild  diluent  drinks,  and  slightly  alkaline  waters,  such  as  the 
potass,  or  the  Vichy  water,  generally  answer  every. purpose.  In 
the  chronic  form  of  the  evil,  attended  by  more  or  less  hypertro- 
phy of  the  tissue  of  the  urethra,  complete  rest  is  an  essential,  and 
the  avoidance  of  any  cause,  such  as  sexual  intercourse,  by  which 
congestion  about  the  pelvic  viscera  can  be  excited  or  maintained. 
Generally,  indeed,  if  the  urethral  hypertropiiy  is  at  all  considera- 
ble, the  act  of  intercourse  is  attended  b}-  so  much  discomfort  as 
to  lead  to  its  discontinuance.  One  or  two  leeches  applied  by 
means  of  a  small  glass  leech-tube  to  the  urethra  itself,  and  re- 
peated weekly,  or  twice  a  week  for  a  short  time,  generally  afford 
very  great  relief.  Frequent  cold  sponging,  and  the  use  of  cold 
astringent  lotions,  or  of  cold  hip-baths,  confirms  the  improvement 
which  depletion  and  careful  dietetic  measures  had  obtained.  I 
have  found,  however,  that  any  attempt  at  the  employment  of 
pressure,  as  suggested  by  Sir  C.  Clarke,  was  attended  by  more 
annoyance  than  advantage,  and  therefore  content  myself,  as  the 
removal  of  the  hypertrophied  tissue  cannot  be  expected,  with  ex- 
plaining to  the  patient  the  nature  of  her  ailment,  and  the  simple 
means  by  which,  though  she  cannot  expect  a  cure,  she  may  always 
obtain  for  herself  great  alleviation. 

Under  the  name  of  vascular  tumors  of  the  orifice  of  the  meatus 
urinarius.  Sir  C.  Clarke  described  a  very  painful  aft'cction,  which 
though  it  had  not  altogether  escaped  the  observation  of  previous 
writers,  had  yet  received  comparatively  little  notice.  These  tumors 
are  hypertrophied  papillae  made  up  of  elementary  fibro-cellular  tis- 
sue, covered  by  a  layer  of  tessellated  epithelium,  the  thickness  of 
which  varies  much  in  difierent  instances,  and  very  richly  supplied 
with  vessels.'  They  grow  from  the  lower,  and  often  also  from 
the  lateral  margin  of  the  orifice  of  the  urethra,  but  they  scarcely 
ever  involve  the  whole  of  its  circumference,  or  spring  from  its 
upper  border.  Sometimes  they  are  turnished  with  a  pedicle,  the 
bulk  of  the  growth  in  that  case  projecting  beyond  the  urethral 
orifice,  but  often  they  are  sessile,  and  then  distend  its  aperture, 
leaving  a  narrow  passage  at  the  upper  part  of  the  urethra,  through 

1  Sir  C.  Clarke,  Diseases  of  Women,  Part  I,  p.  803.  Paget,  oj).  cit.,  vol.  ii,  p.  282, 
note  ;  Burford,  I^orman,  London  and  Ed.  Monthly  Journal,  June,  1849,  Avhieh  con- 
tains an  account  of  their  microscopic  structure  by  Mr.  Quckett;  and  again  in 
London  Journal  of  Medicine,  Feb.  1852,  p.  146. 


FROM    THE   URETHRA.  501 

wliich  the  urine  flows,  though  not  readily;  the  obstacle  to  its  out- 
flow occasioning  considerable  dilatation  of  the  canal  behind  the 
excrescence.  These  growths  vary  much  both  in  size,  in  vascu- 
larity, and  in  sensitiveness ;  but  they  do  not  in  general  exceed  the 
bigness  of  a  currant,  are  frcquentlj"  smaller ;  and  I  have  never  seen 
one  larger  than  a  hazel  nut,  thongh  instances  are  alleged  of  their 
attaining  the  size  of  a  pigeon's  eo^g,  or  even  a  still  greater  magni- 
tude. Their  vascularity  and  their  sensitiveness  are  generally  i»ro- 
portionate  to  each  other ;  those  whose  color  is  most  vivid,  bleeding 
the  most  easily,  having  apparently  the  most  delicate  epithelial 
covering,  and  the  most  exquisite  tenderness. 

The  most  vascular  of  these  growths  are  of  a  bright  cherry-red, 
while  those  which  are  least  so  are  of  the  same  color  with  the  sur- 
rounding mucous  membrane.  Though  frequently  solitary,  yet,  in 
many  instances,  two  or  three  separate  growths  are  situated  at  the 
edge  of  the  urethra,  or  just  within  its  orifice  ;  and  it  is  by  no  means 
unusual  to  observe  several  small  excrescences  of  a  similar  charac- 
ter, but  generally  of  a  much  smaller  size,  springing  from  diiierent 
points  of  the  vestibulum.  Sometimes,  indeed,  they  are  scarcely 
larger  than  the  head  of  a  blanket  pin,  but  of  a  vivid  red  color, 
and  most  exquisitely  tender.  Those  growths  which  occupy  the 
urethra  seldom  extend  above  a  sixth,  or  a  fourth  of  an  inch  along 
its  canal,  but  now  and  then  they  reach  further,  and  cases  are  re- 
lated in  which  almost  the  whole  length  of  the  urethra  has  been 
the  seat  of  these  excrescences,  a  condition  the  more  unfortunate 
sin6e  it  is  almost  impossible  of  cure. 

The  symptoms  to  wliich  these  outgrowths  give  rise  are,  pain  in 
micturition,  sometimes  of  extreme  severity,  though  in  other  cases 
in  which  the  sensibility  of  the  tumor  is  lowest,  the  sensation^  is 
one  of  discomfort  rather  than  of  severe  suffering.  Coupled  with 
this,  there  is  in  many  instances  pain  on  any  attempt  at  sexual 
intercourse,  and  this  pain  is  often  aggravated  by  the  presence  of 
the  small  outgrowths  to  which  reference  has  been  made  about  the 
vestibulum.  The  presence  of  these  growths  does  not  produce  a 
frequent  desire  to  pass  water,  but,  on  the  contrary,  it  not  infre- 
quently happens  that,  on  account  of  the  pain  which  attciuls  the 
effort  at  micturition,  patients  acquire  the  habit  of  retaining  their 
urine  for  a  longer  time  than  natural.  When,  however,  the  long 
continuance  of  the  irritation  has  produced  that  thickening  of  the 
urethra  which  was  spoken  of  a  short  time  ago,  its  characteristic 
symptoms  manifest  themselves  in  a  constant  sense  of  weight  and 
aching,  and  frequent  desire  to  pass  water. 

It  is  not  possible  to  say  on  what  these  outgrowths  depend, 
though  they  have,  in  my  experience,  been  much  less  conmion  in 
the  single  than  in  the  married,  and  in  the  young  than  in  the 
middle  aged.  Thus  of  21  cases  of  Avhich  I  preserved  a  record,  18 
occurred  in  married  women,  only  3  in  those  who  were  single. 
Five  of  the  patients  were  U|>wards  of  50  years  old,  4  betwi'en  40 
and  50,  G  between  30  and  40,  5  between  20  and  30,  and  oidy  one 
was  under  20  years  of  age.     All  but  three  of  the  married  women 


602  VASCULAR    TUMORS    OF    URETHRA. 

had  given  birth  to  children,  and  in  the  case  of  some  of  the  patients 
there  was  a  history  of  previous  vaginitis  or  gonorrlioea;  a  circum- 
stance which  favors  the  suggestion  of  Scanzoni/  that  in  some 
instances  these  outgrowths  depend  on  previous  chronic  urethritis. 

There  is  a  condition  in  some  respects  allied  to  this,  and  produc- 
tive of  some  of  the  same  symptoms,  in  wdiich  a  tumor  occn})ies 
and  obstructs  the  orifice  of  the  urethra,  formed  apparently  only 
by  a  hypertrophied  condition  of  the  otherwise  unaltered  mucous 
mem])rane,  a  fold  of  Avhich  nearly  blocks  up  the  canal,  causing  it 
to  dilate  behind  the  point  of  obstruction,  and  thus  renders  the 
act  of  micturition  difficult  and  painful,  though  unattended  by  the 
acute  sensibility  which  accompanies  the  genuine  vascular  tumor. 
In  many  instances  this  hypertrophy  of  the  urethral  mucous  mem- 
brane is  associated  witli  the  presence  of  a  number  of  small  out- 
growths ot  mucous  membrane,  fringing  the  orifice  of  the  vulva, 
or  growing  from  the  outer  edge  of  the  lips  of  the  urethra,  and 
productive  of  some  degree  of  irritation,  and  even  of  inconveni- 
ence in  sexual  intercourse. 

The  treatment  of  these  excrescences,  of  wlultever  kind,  is  abun- 
dantly simple,  and  consists  in  their  complete  removal,  and  in  the 
apppli cation  to  the  surface  whence  they  sprang  of  some  strong 
caustic,  or  of  the  actual  cautery,  in  order  to  prevent  their  repro- 
duction, which  is  otherwise  very  apt  to  occur,  I  am  accustomed 
always  to  ap]d\'  the  actual  cautery  for  this  purpose,  both  because 
it  most  etfectually  arrests  that  flow  of  blood,  which  I  have  known 
in  one  or  two  instances  where  it  was  not  emjdoyed  to  be  so  con- 
siderable as  to  excite  alarm,  and  also  because  it  has  seemed  to  me 
to  be  more  efficient  tlian  any  form  of  caustic  in  preventing  the 
reproduction  of  the  growth.^  The  operation,  though  of  very  short 
duration,  is  so  painful,  that  very  few  patients  can  dispense  with 
the  use  of  cliloroform,  and  its  administration  is  the  more  needed 
since  it  is  essential  that  the  patient  should  remain  absolutely 
quiet  lest  the  urethra  should  be  injured.  Care  to  avoid  this  acci- 
dent is,  indeed,  the  only  [trecaution  specially  called  for  during  the 
excision  of  these  growths;  this,  however,  is  all  the  more  neces- 
sary, since  injury  to  the  orifice  of  the  urethra  has  sometimes  been 
followed  by  incontinence  of  urine,  or  by  difficulty  in  its  retention. 

If  after  the  excision  of  these  growths  there  should  remain  any 
one  spot  where  their  removal  has  not  been  quite  complete,  or  if, 
though  no  excrescence  be  present,  a  state  of  morbid  vascularity 
of  the  urethra  should  continue,  such  as  sometimes  precedes  or  ac- 
companies the  formation  of  these  little  excrescences,  either  condi- 
tion is  generally  capable  of  removal  by  the  application  twice  a  day, 
for  two  or  three  weeks,  of  the  undiluted  liquor  plumbi. 

1  Kiwisch,  op.  cit.,  vol.  iii,  p.  298. 

2  Dr.  3Icdoro,  of  Padua,  recommended  some  years  ago  in  an  Italian  journal, 
■whence  it  was  extracted  in  Schmidt's  Jahrbiic/ier,  vol.  xxxvii,  p.  186,  the  u.«e  of 
the  actual  cautery,  without  previous  excision,  for  the  removal  of  these  growths. 
I  have  not  tried  it  in  this  manner,  but  as  an  adjunct  to  excision  I  believe  it  to  be 
most  desirable. 


CHRONIC    ULCERATION    OF    URETHRA.  503 

There  is  a  condition  of  cJironic  ulceration  of  the  urethra  of  wliicli 
I  have  met  with  a  few  instances,  and  which  it  may  ])e  wortli  wliile 
to  refer  to  here,  since,  thongli  I  believe  it  to  be  of  sy})liilitic  origin, 
and  therefore  to  lie,  strictly  speaking,  beyond  my  province,  I  yet 
have  found  no  mention  of  it  in  treatises  on  the  venereal  disease. 

The  afltection  has  come  six  times  under  my  observation  :  twice 
in  married  women,  who  acknowledged  to  having  suffered  from 
venereal  disease  ;  and  four  times  in  women  of  unchaste  life,  one 
of  whom  was  at  the  same  time  sufiering  from  a  secondary  syphi- 
litic eruption.  In  every  instance  the  })atients  alleged  either  that 
they  had  been  aw^are  of  the  ulceration  of  the  urethra,  or  that  they 
had  experienced  difficult  and  painful  micturition  for  periods  vary- 
ing from  nine  months  to  five  years.  Twice  the  disease  was  asso- 
ciated witli  an  excrescence  from  the  mucous  membrane  of  the 
urethra,  having  the  characters  of  the  less  vascular  form  of  those 
outgrowths  which  have  just  been  described.  The  ulceration  ap- 
pears to  commence  at  the  orifice  of  the  urethra,  and  to  extend 
thence  inwards  towards  the  bladder,  producing  as  it  extends  a 
great  widening  of  the  canal,  and  a  patulous  state  of  its  orifice,  so 
that  the  finger-tip  can  enter  it  with  ease,  while  the  surface  is  the 
seat  of  large,  firm,  indolent  granulations,  which  secrete  a  small 
quantity  of  a  muco-purulent  fluid,  are  not  in  general  very  tender 
to  the  touch,  but  highly  sensitive  to  the  passage  of  urine.  I  have 
met  with  this  ulceration  of  the  urethra  independent  of  any  other 
disease  of  the  sexual  organs,  but  have  also  observed  it  in  cases 
where  previous  ulceration  had  destroyed  the  clitoris  and  the  nym- 
pha.%  and  have  seen  it  associated  with  uidiealthy  ulceration  about 
the  posterior  conmiissure  of  the  labia  and  the  entrance  of  the  vulva ; 
as  also  with  those  small  condylomatous  growths  about  the  vulva 
in  cases  of  vascular  tumor  of  the  urethra,  and  these  latter,  indeed, 
are  more  commonly  present  than  absent.  When  the  disease  has 
advanced  far,  or  has  been  of  long  standing,  the  cellular  tissue  be- 
neath the  urethra  usually  becomes  considerably  thickened,  and 
I  have  seen  the  lower  wall  of  the  urethra  represented  by  a  dense, 
cartilaginous  substance,  not  unlike  one  of  the  lips  of  a  hypertro- 
pliied  and  partially  procident  cervix  uteri ;  while  on  two  occasions 
I  have  been  able  to  carry  my  finger  along  the  whole  length  of  the 
canal  into  the  bladder. 

Even  when  not  very  far  advanced  this  disease  causes  difficulty 
in  the  retention,  or  actual  incontinence  of  urine,  while,  when  it  has 
extended  along  the  whole  canal,  and  left  its  aperture  })erniancntly 
patulous,  the  patient  becomes  almost  completely  unable  to  retain 
her  urine  at  all.  One  such  case  I  saw  in  a  young  woman,  aged  22, 
in  whom  there  was  not  the  least  power  to  hold  the  urine:  an  in- 
firniity  that  she  said  had  existed  man}'  months.  I  gave  her  an 
elastic  pessary  to  wear,  which,  by  pressing  against  and  mechani- 
cally closing  the  urethra,  rendered  her  more  comfortable.  Once, 
also,  I  saw  a  prostitute  whose  ulcerated  urethra  was  so  widely 
open  that  two  fingers  could  be  passed  into  the  bladder  with  ease. 
She  was  constantly  soaked  with  urine ;  but  in  spite  of  her  loath- 


504  CHRONIC    ULCERATION    OF    URETHRA. 

some  condition  still  plied  her  trade,  and  no  argument  could  induce 
her  to  abandon  it. 

"Whether  these  cases  are  truly  syphilitic,  or  whether  they  de- 
serve more  properly  to  be  classed  with  the  rodent  ulcer,  or  lupus 
exedens,  I  am  at  present  unprepared  to  say.  On  the  one  hand 
their  directly  syphilitic  origin  may  appear  to  be  rendered  doubt- 
ful by  the  circumstance  that  in  only  one  instance  was  there  any 
evidence  of  then  existing  venereal  taint;  while  on  the  other  hand 
the  affection  of  the  urethra  differs  from  the  other  forms  of  rodent 
ulcer,  lupus,  or  esthiomene,  in  being  unattended  by  the  same  dis- 
position to  great  thickening  of  the  adjacent  tissues,  which,  in  the 
case  of  lupus  of  the  vulva,  approximates  the  affection  at  a  first 
glance  very  closely  to  elephantiasis. 

In  its  less  severe  forms  I  have  seen  this  condition  greatly  im- 
prove, the  pain  in  passing  water  diminish,  and  the  ulcerations 
cicatrize  under  the  use,  twice  a  day,  of  a  lotion  composed  of  .5j  of 
oxide  of  zinc  suspended  by  means  of  half  an  ounce  of  mucilage  in 
an  ounce  of  water,  and  injected  into  the  urethra,  while  the  surface 
was  shielded  from  the  irritation  of  the  urine  by  the  abundant  ap- 
plication to  it  of  the  zinc  ointment.  At  the  same  time  the  con- 
tinued employment  of  the  iodide  of  potass  and  syrup  of  iodide  of 
iron  have  seemed  to  exercise  a  beneficial  influence  on  the  patient's 
general  health,  which  in  every  instance  has  appeared  to  be  indif- 
ferent. For  the  most  part,  however,  these  measures  seldom  prove 
more  than  palliatives  ;  but  in  one  case  of  very  long  standing,  when 
other  means  had  completely  failed,  the  repetition  three  or  four 
times  of  the  actual  cautery  was  of  the  most  signal  benefit.  It  was 
of  course  applied  but  light!}',  so  as  not  to  destroy  the  tissues  to 
any  depth ;  and  under  its  use  the  large  granulations  by  degrees 
disappeared,  leaving  a  healthy  surface  beliind ;  the  pain  in  mic- 
turition subsided;  the  wide  urethra  contracted  its  dimensions; 
and  the  patient  regained  the  power  of  holding  her  urine.  I  am 
not  prepared,  however,  to  say  how  for  in  this  instance  the  amend- 
ment was  lasting,  or  how  far  the  most  extreme  cases  would  be 
amenable  to  the  same  treatment. 

As  we  approach  the  end  of  these  lectures,  the  interest  which  I 
would  fain  persuade  myself  attached  in  some  degree  to  the  subjects 
that  were  brought  before  your  notice  diminishes,  I  fear,  at  almost 
every  step.  We  have  come  now  to  the  study  of  ailments  purely 
local  in  their  character,  often,  indeed,  painful,  always  annoying, 
sometimes  dangerous,  but  which  yet  afibrd  small  matter  fur  inves- 
tigation, and  seem  to  yield  little  scope  for  the  exercise  of  the 
higher  qualities  of  the  practitioner  of  medicine.  But  an  observa- 
tion which  I  made  some  years  ago,  when  addressing  the  seniors  of 
our  profession,  may  perhaps  be  repeated  without  apology  to  those 
who  are  but  beginning  the  exercise  of  medicine,  and  on  whom  it 
cannot  be  too  deeply  impressed  that  "  the  thousand  smaller  ills 
to  which  mankind  is  subject,  bring,  in  their  frequent  repetition, 
as  much  suftering,  cause  as  much  sorrow,  and  therefore  are  as 
worthy  of  our  heartiest  labor  to  understand,  and  of  our  best  efforts 


ACUTE    INFLAMMATION    OF    THE    VAGINA.  505 

to  relieve,  as  those  perilous  visitants — inflammations,  fevers,  apo- 
plexies, wbicli  threaten  lite  only  at  long  intervals,  or  on  rare  occa- 
sions."^ 

With  this  preface  let  us  now  pass  to  the  study  of  the  diseases  of 
the  vagina,  and  of  the  external  organs  of  generation.  And  first 
among  the  ailments  of  the  vagina  we  may  notice,  as  we  have  done 
in  the  case  of  other  organs,  those  affections  which  are  the  result 
of  inflammation  either  in  an. acute  or  in  a  chronic  Form. 

The  acute  form  of  inflammation  of  the  vagina,  apart  from  those 
cases  in  which  it  occurs  in  the  puerperal  state,  is  probably  oftenest 
due  to  impure  sexual  intercourse.  Between  gonorrhoea,  however, 
and  acute  vaginitis  dependent  on  any  other  cause,  there  does  not 
seem  to  be  any  certain  distinction  furnished  either  by  the  character 
of  the  symptoms  or  by  their  severity,  while  a  similar  treatment  is 
applicable  to  both.  When  dependent  on  the  contagion  of  gonor- 
rhoea, the  symptoms  generally  commence  within  three  days  after 
the  suspected  intercourse  ;  but  vaginitis  may  be  equally  excited 
by  exposure  to  cold  or  wet,  and  especially  by  getting  wet-footed; 
by  local  irritation  of  the  sexual  organs,  by  intemperate  or  unac- 
customed sexual  intercourse,  and  to  this  latter  cause  attacks  of 
moderately  severe  vaginitis  are  not  very  rarely  due  in  newly- 
married  women. 

A  disagreeable  sense  of  fulness,  heat  and  tenderness  about  the 
vulva,  with  frequent  desire  to  pass  water,  and  pain  and  scalding 
in  the  act  of  micturition,  are  the  symptoms  with  which  it  sets  in. 
Sometimes  there  is  associated  with  these  discomforts  great  swell- 
ing of  the  labia,  which  are  so  tender  that  the  sitting  posture  can 
scarcely  be  borne,  while  a  feeling  of  aching  and  weight  extends 
along  the  perineum,  and  considerable  tenderness  of  the  hypogas- 
trium  announces  that  the  bladder  has  become  involved  by  the 
advance  of  the  inflammation.  For  the  first  twenty-four  hours  the 
customary  secretion  is  suppressed;  but  a  discharge  then  begins 
to  be  poured  out  in  great  abundance  ;  yellow,  acrid,  purulent, 
occasionally  streaked  with  blood,  always  of  an  offensive  smell. 
Tliis  discharge  is  chiefly  furnished  from  the  lower  extremity  of  the 
vagina,  though  the  inner  surface  of  the  nymphte,  and  the  parts 
about  the  vestibulum  also  contrilnite  to  it,  and  sometimes  the  in- 
flammation extends  along  the  vaginal  canal,  the  whole  of  which 
may  then  pour  out  the  discharge.  In  a  few  instances  the  mischief 
extends  even  further;  I  have  seen  internal  metritis  supervene 
uj>on  inflammation  of  the  vagina,  and  two  successive  attacks  of 
vaginitis,  after  an  interval  of  eighteen  months,  were  followed  in 
the  same  patient  l)y  such  severe  peritonitis  as  to  call  on  each  occa- 
sion for  the  abstraction  of  blood.  These,  however,  are  purely 
exceptional  occurrences  ;  and  in  most  instances  the  affection  re- 
mains limited  to  the  vulva  and  the  lower  part  of  the  vagina. 

If  the  parts  are  examined  during  the  acute  stage  of  the  affection, 
they  appear  of  a  bright  red  color,  shining,  and  swollen,  while  if 

•  Croonian  Lectures,  8vo.,  London,  1854,  p.  94. 


506  ACUTE    VAGINITIS. 

tlie  finger  is  introdnced  into  the  vagina,  the  heat  of  the  parts  will 
be  found  to  be  greatly  increased.  The  introduction  of  the  finger 
even  is  almost  always  excessively  painful,  and  the  tenderness  is 
so  great  as  to  render  the  employment  of  the  speculum  quite  im- 
possible. During  the  severity  of  the  onset  of  the  disease,  an 
abscess  sometimes  forms  in  one  or  other  labium,  usually,  if  not 
invariably,  having  its  seat  in  Cowper's  gland,  but,  supposing  this 
not  to  be  case,  the  swelling  and  tenderness  generally  abate  in  four 
or  five  days,  the  discharge  loses  its  acrid  character  and  oftensive 
odor,  and  except  that  its  quantity  is  excessive,  differs  little  from 
the  muco-purulent  secretion  which  constitutes  ordinary  leucor- 
rhoea. 

These  changes  in  the  character  of  the  discharge  appear  to  depend 
on  the  more  or  less  abundant  presence  of  pus  globules,  and  of  the 
tessellated  epithelium  of  the  vagina:  desquamation  of  which  takes 
place  so  very  abundantly  in  vaginal  leucorrhoea  that  it  lurnishes 
us,  as  Dr.  Tyler  Smith'  has  shown,  with  a  very  valuable  means  of 
determining  the  source  of  the  discharge  from  which  a  patient 
suffers.  To  a  very  great  extent  also  similar  information  may  be 
gathered  from  the  discovciy  in  the  discharge  of  a  small  infusorial 
animalcule  first  described  by  M.  Donnd,  and  once  sui)])()sed  by 
him  to  be  pathognomonic  of  gonorrlueal,  as  distinguished  from 
simple  vaginitis.  He  soon,  however,  found  cause  to  renounce  this 
opinion,  though  he  still  alleges  that  the  Trichomonas  is  never  ob- 
served in  healthy  vaginal  mucus,  but  only  in  the  secretion  when 
containing  a  large  admixture  of  pus  globules.  This  latter  state- 
ment, too,  is  confirmed  by  the  researches  of  Kcilliker  and  Scanzoni,^ 
who  further  add  the  remark,  that  while  never  present  in  the  cer- 
vical mucus,  and  by  that  circumstance  plainly  demonstrated  to 
be  sometliing  more  than  a  mere  cell  of  ciliary  epithelium,  as  has 
been  sometimes  imagined,  the  Trichomonas  is  on  the  one  hand  not 
constantly  present  in  vaginal  leucorrha>a,  and  on  the  other  the 
existence  of  the  disease  in  a  grave  form  is  by  no  means  essential 
to  its  development,  since  it  is  found  in  some  persons  in  ap[)arent 
health,  and  in  whom  the  admixture  of  pus  globules  with  the  dis- 
charge though  evident,  is  yet  not  very  considerable. 

It  may  perhaps  be  added,  that  as  the  microscope  fails  to  furnish 
us  with  a  means  of  distinguishing  between  gonorrhoeal  and  sim[)le 
vaginitis,  so  no  S3'mptom  or  combination  of  symptoms  is  absolutely 
conclusive  on  this  point.  Tlie  amount  of  affection  of  the  urethra 
certainly  strengthens  the  suspicion  of  the  gonorrhoeal  origin  of 
the  disease ;  but  urethral  inflammation  and  discharge  are  some- 
times present  in  cases  where  no  suspicion  of  gonorrha^a  can  for  a 
moment  be  entertained,  and  according  to  M.  Ricord,  are  likewise 
absent  in  cases  avowedly  due  to  impure  intercourse,  about  once  in 
every  three  times. 

1  On  Leucor7-hcea,&c.,  chap,  iv,  pp.  51-79. 

2  See  with  reference  to  these  points,  the  very  elaborate  investigations  of  Kolliker 
and  Scanzoni,  on  the  secretion  of  the  mucous  membrane  of  the  vagina  and  cervix 
uteri,  in  Scanzoni's  Beiirage,  &c.,  vol.  ii,  VViirtzburg,  1855,  pp.  128-146. 


CHRONIC    VAGINITIS.  607 

It  is  comparatively  seldom,  at  any  rate  in  private  practice,  that 
vaginitis  or  vaginal  leucorrhoea  comes  under  our  notice  in  its  acute 
stage.  If  it  does,  the  employment  of  tepid  hip-baths,  of  tei)id 
vaginal  injections,  rest,  and  mild  laxatives,  usually  suffice  to  afford 
relief,  while  as  the  inflanimatf)ry  symptoms  subside  injections  of 
cold  water,  of  the  diluted  liquor  [)lumbi,  of  solutions  of  sulphate 
of  zinc,  or  of  alum,  will  restrain,  and  in  a  week  or  two  put  a  stop 
to  the  profuse  discharge  which  for  a  season  remains  behind.  Xow 
and  then,  however,  if  the  pain  is  ver}-  severe,  the  tenderness  great, 
and  the  swelling  of  the  labia  considerable,  it  is  expedient  to  apply 
eight  or  a  dozen  leeches  to  the  vulva,  to  encourage  the  bleeding  by 
a  warm  hipbath,  and  a  warm  bread-and- water  poultice,  and  after- 
wards to  keep  warm  fomentations  of  two  parts  of  the  decoction  of 
poppy  and  one  part  of  the  diluted  lead  lotion  constantly  ap))licd 
to  the  vulva.  These  measures  will,  in  most  cases,  within  less  than 
twenty-four  hours,  reduce  a  state  of  previously  intense  suft'ering 
to  one  of  very  bearal)le  discomfort.  Sometimes,  however,  the  diffi- 
culty and  pain  in  passing  water  continue  very  distressing,  and  in 
that  case  the  extract  and  decoction  of  uva  ursi  with  small  doses  of 
liquor  potassa  and  of  the  tincture  of  henbane  seldom  fail  to  afl'ord 
very  speedy  and  very  marked  relief.  I  am  disposed  to  think, 
indeed,  from  my  hospital  experience,  that  the  complication  of  vagi- 
nitis with  some  degree  of  inflanmiation  of  the  bladder  often  fails 
to  receive  that  degree  of  attention  which  it  merits ;  for  it  has  hap- 
pened to  me  not  infrequently  to  meet  with  patients  in  whom  very 
distressing  dysuria,  the  evident  result  of  chronic  cystitis,  was 
referred  back  to  some  acute  attack  of  leucorrhoea  or  gonorrhoea 
which  had  occurred  months  before. 

But  it  is,  as  I  have  stated,  a  more  chronic  form  of  ailment  with 
which  we  oftener  have  to  do,  and  tliis  not  only  in  cases  where  a 
leucorrhoeal  discharge  has  been  left  behind  after  the  subsidence  of 
the  acute  attack,  but  in  a  large  number  of  instances  where  the 
ailment  has  been  chronic  from  the  outset.  Such  are  many  of  the 
cases  of  leucorrhoea  that  occur  in  women  exhausted  by  frequent 
childbearing,  or  by  prolonged  lactation,  or  by  menorrhagia.  Such, 
too,  are  the  instances  in  which  leucorrhoea  accompanies  cldorosis, 
and  of  the  same  kind  are  those  abundant  discharges  from  the 
sexual  organs  which  take  place  in  strumous  children,  and  which, 
sometimes  assuming  a  subacute  character,  and  being  associated 
with  much  swelling  of  the  external  parts,  have  been  erroneously 
supposed  to  be  due  to  criminal  attempts  at  intercourse.  I  may 
just  add,  however,  that  the  discharge  in  the  case  of  the  child  takes 
place  almost  entirely  from  the  parts  in  front  of  the  hymen,  and  is 
the  result,  therefore,  rather  of  vulvitis  than  of  vaginitis.  Any 
condition  which  maintains  or  is  dependent  on  habitual  venous 
congestion  of  the  abdominal  viscera  is  apt  to  be  associated  with 
vaginal  leucorrhoea.  Hence  the  discharge  is  often  observed  not 
only  in  women  who  sutler  from  ovarian  or  other  abdominal  tu- 
mors, but  also  in  })ationts  liable  to  disorders  of  the  liver,  or  to 
hemorrhoidal  aftections,  or  who  sutler  from  hal>itual  constipation. 


508  TREATMENT    OF 

Uterine  tumors,  and  uterine  misplacements  are,  as  it  is  almost 
needless  to  observe,  apt  to  be  associated  with  vaginal  leucorrlioea; 
while  even  in  those  cases  in  wliich  the  greater  proportion  of  the 
discharge  is  poured  out  from  the  interior  of  the  uterus,  there  is 
almost  invariably  a  large  admixture  of  secretion  furnished  from  the 
walls  of  the  vagina. 

It  is  obvious  that  the  chances  of  cure  of  this  chronic  vaginal 
leucorrlioea  depend  entirely  on  the  uncomplicated  character  of  the 
ailment,  or  on  the  diseases  with  which  it  is  associated  being  of  a 
kind  to  admit  of  removal.  Thus,  the  leucorrlioea  attendant  on 
uterine  tumors,  while  in  itself  it  need  not  excite  any  solicitude, 
yet  scarcely  admits  of  cure,  its  restraint  by  astringent  lotions 
being  all  that  can  be  attempted.  For  the  same  reason,  too,  those 
vaginal  discharges  which  are  associated  with  abdominal  tumors 
do  not  admit  of  cure;  while  in  those  instances  in  which  they 
accompany  hepatic  disorder  or  abdominal  congestion,  as  is  not  in- 
frequently the  case  in  women  after  the  middle  period  of  life,  and 
in  whom  menstruation  has  ceased,  the  cure  of  the  local  ailment 
depends  on  the  removal  of  the  constitutional  disorder.  The 
leucorrhoea  of  the  feeble  and  chlorotic  obviously  needs  a  tonic 
plan  of  treatment,  and  the  administration  of  chalybeates,  in  addi- 
tion to  the  employment  of  local  remedies ;  while,  in  the  case  of 
children,  it  is  always  necessaiy  to  ascertain  that  the  discharge 
from  the  vulva  is  not  produced  by  the  irritation  of  ascarides  in 
the  rectum. 

But,  not  to  dwell  upon  points  which  are  almost  self-evident,  I 
must  just  notice  some  of  the  more  useful  astringent  applications; 
for  to  these  local  means  we  must  chiefly  trust,  since  there  are  no 
internal  remedies  that  exercise  a  direct  influence  on  vaginal  dis- 
charges in  the  same  way  as  cubebs  and  copaiba  restrain  uterine 
leucorrhoea.  First  among  these  means  stands  the  abundant  use  of 
cold  water,  either  for  ablution,  for  vaginal  injection,  or  in  the  form 
of  the  hip-bath;  for  simple  though  it  is,  and  therefore  often  too 
little  had  recourse  to,  it  is  not  only  very  efiicacious,  but  in  many 
instances  suffices  of  itself  to  arrest  the  discharge,  and,  if  continued, 
to  prevent  its  return.  The  water  may  be  rendered  more  astringent 
by  the  addition  of  about  a  quarter  of  an  ounce  of  alum  to  each 
pint  of  water  used  for  injection,  or  by  mixing  a  quarter  of  a  pound 
of  alum  with  the  water  used  for  the  hip-bath,  and  which  should 
be  employed  either  on  rising  from  bed,  or,  at  any  rate,  during  the 
morning  hours,  not  just  before  going  to  rest  at  night.  The  alum 
bath  has  the  advantage  of  being  one  of  the  best  astringents,  and 
also  of  being  one  of  those  remedies  with  which  a  patient  can 
always  supply  herself  without  the  intervention  of  the  chemist.  If, 
however,  it  should  fail,  as  all  local  applications,  if  long  continued, 
are  in  turn  apt  to  do,  a  more  powerful  injection  may  be  obtained 
by  the  addition  of  a  drachm  of  tannin  to  each  two  drachms  of  the 
alum,  or  by  dissolving  the  alum  in  decoction  of  oak-bark  instead 
of  in  water.  Both  of  these  lotions,  however,  have  the  disadvantage 
of  staining  the  linen  almost  as  indelibly  as  the  nitrate  of  silver, 


VAGINAL    LEUCOllRHCEA.  509 

though  not  of  so  dark  a  color.  The  lead  lotions  of  various  strengths, 
and  lotions  of  sulphate  of  zinc,  either  alone,  or  in  comlnnation 
with  alum,  may  also  be  employed,  if  other  means  fail ;  hut  iailures 
very  often  depend  on  the  inefhcient  use  of  the  injection,  rather 
than  on  any  fault  in  the  remedy  itself;  and  it  is  therefore  always 
of  importance  to  ascertain  that  the  patient  employs  a  syringe  of 
sufficient  size,  and  that  she  uses  the  injection  when  in  a  recumbent 
and  not  in  a  sitting  posture.  1{  is  also  always  desirable  that  cold 
w^ater  shoukl  be  injected  into  the  vagina,  so  as  to  remove  the  dis- 
charge as  much  as  possible  before  the  medicated  injection  is 
employed. 

I  have  no  personal  experience  of  the  use  of  nitrate  of  silver  in 
solution  or  in  substance  in  cases  of  chronic  leucorrhoea.  There  can 
be  no  doubt,  however,  but  that  in  instances  of  very  obstinate  dis- 
charge after  acute  gonorrheal  vaginitis,  the  remedy  has  proved  of 
great  service.^  For  veiy  obstinate  cases  of  vaginal  leucorrhcjea  a 
plan  of  iScanzoni's  will  probably  be  found  successful.^  lie  intro- 
duces into  the  vagina  a  plug  of  cotton-wool,  the  outer  surface  of 
which  has  been  bestrewn  with  alum  in  .powder;  or  if  there  be 
much  sensitiveness  of  the  parts,  with  a  mixture  of  one  part  of  alum 
and  one  or  two  parts  of  loaf-sugar.  This  plug  should  not  be  allowed 
to  remain  longer  than  twelve  hours  at  a  time,  nor  should  its  intro- 
duction be  repeated  oftener  than  every  second  or  third  day,  injec- 
tions of  tepid  water  being  employed  in  the  intervals.  The  chief 
drawback  from  the  adoption  of  this  plan  seems  to  be  that  unless 
carefully  watched  a  very  troublesome  vaginitis  may  be  induced  by 
the  remedy,  which  in  that  case  may  aggravate  instead  of  arresting 
the  discharge.  M.  Guerin,^  whose  experience  in  the  management 
of  this  class  of  ailments  is  so  extensive,  speaks  also  in  the  .highest 
terms  of  the  result  of  introducing  a  plug  of  cotton-wool,  of  the  size 
of  a  walnut,  and  containing  about  a  teaspoonful  of  powdered  alum, 
through  the  speculum,  and  quite  up  to  the  fundus  of  the  vagina, 
where  he  allows  it  to  remain  live  or  six  days.  lie  does  not  seem 
to  have  experienced  any  graver  inconvenience  from  its  use  than  a 
little  irritation  of  the  mucous  membrane,  near  the  fourchette,  as 
the  dissolved  alum  comes  in  contact  with  it,  and  which  is  readily 
removed  by  washing  with  tepid  water.  For  the  majority  of  cases 
even  of  very  chronic  leucorrhcea,  however,  a  very  efficacious  and 
probal)ly  a  safer  mode  of  keeping  the  astringent  in  constant  con- 
tact with  the  vaginal  walls  is  furnished  by  the  use  of  the  alum  or 
tannin  ])essaries  of  Dr.  Simpson.* 

Attention  was  specially  drawn  some  few  years  ago  by  M.  I)eville, 
of  Paris,*  to  what  he  believed  to  be  a  previously  unnoticed  form 

'  Acton,  On  the  GeneraHve  Organs,  &c.,  p.  287.  '  Op.  cit.,  p.  287. 

*  Miila'/ics  des  Orgnnes  Qenitaiix  ExteTUcs  dc  la  Femmr,  8vo.,  Paris,  1804,  p.  .30,3. 

*  Ed.  Monlhhj  Journal,  .Juno,  18^8,  and  Ohniefric  U'vrl.s,  p.  'J8.  Fornuihc  are 
given  tliero  for  various  iiinds  of  possaries.  Tlio  nlum  and  tannin  arc  made  as  fol- 
lows: R.  Tanniiiic  ^ij,  Cene  all):i>  ^v,  Axuniciie  ,:^vi,  misce,  ct  divide  in  Pessos 
quatuor.  R.  Alum,  .xulph.  3J,  pulv.  Catuciiu  3J,  Cerje  fluvaa  3J,  Axungiae  gvsa. 
Misce,  et  divide  in  Pessos  quatuor. 

*  Archives  de  Medecine,  Quatrifeme  S6rie,  tome  v,  pp.  305,  417. 


510  GRANULAR    VAGINITIS. 

of  inflammation  of  the  vagina,  and  to  which,  from  its  anatomical 
peculiarities,  he  applied  the  name  of  granular  vaginitis.  These 
peculiarities  consist  in  the  presence  of  numerous  round,  shot-like 
bodies  of  a  more  vivid  red  color  than  the  adjacent  tissues,  in  the 
depressions  between  the  rugte  of  the  vagina,  and  especially  abun- 
dant towards  the  upper  part  of  the  canal.  These  bodies  were  im- 
agined to  be  the  hypertrophied  follicles  of  the  mucous  meml)rane, 
and  were  supposed  to  bear  a  large  share  in  secreting  the  abundant 
thick  yellow  discharge  which  was  poured  out  from  the  vagina. 
The  affection  was  further  observed  to  be  connected  very  closely 
with  the  pregnant  state,  while  it  scarcely  ever  occurred  in  women 
wlio  had  not  at  some  comparatively  recent  period  given  birth  to 
children. 

The  researches  of  minute  anatomists,  and  especiall}^  those  of  M. 
Mandt,'  have  shown,  however,  that  the  vagina  is  singularly  desti- 
tute of  mucous  follicles,  and  that  these  bodies  are  nothing  else 
than  hypertrophied  papilhe.  This  discovery,  while  it  exjdains  the 
association  of  granular  vaginitis  with  the  pregnant  condition,  at 
once  deprives  it  of  all  claim  to  be  regarded  as  a  peculiar  disease. 
It  is  nothing  else  than  vaginitis,  associated  with  hypertro[)liy  of 
the  vaginal  papillae;  a  physiological  condition  in  pregnancy  ;  one 
which,  independent  of  that  state,  may  follow  or  accompany  long- 
continued  inflammation,  irritation,  or  discharge. 

On  two  occasions  I  have  met  with  ci/sts  projecting  into  the 
vagina.  In  one  instance  their  presence  gave  rise  to  no  inconve- 
nience, and  the  patient,  who  died  of  faecal  abscess,  was  not  aware 
of  their  existence,  though  they  were  so  low  down  as  partially  to 
protrude  through  the  vulva.  Two,  which  were  of  the  size  of  a 
chestnat,  were  connected  with  the  posterior  vaginal  wall,  and  were 
so  firm  as  to  convey  the  impression  of  being  solid  fibrous  growths. 
The  anterior  cyst  was  smaller,  softer,  and  felt  like  a  small  vaginal 
cystocele.  The  surface  of  all  three  was  of  the  same  color  with 
that  of  the  adjacent  vaginal  wall.  After  death,  these  cysts  were 
found  to  have  firm,  thick,  fibrous  walls,  to  be  hned  by  a  polished 
niend^rane,  and  to  contain  a  perfectlv  clear,  glairy,  yellowish,  and 
rather  viscid  fluid,  not  unlike  synovia;  the  anterior  cyst  ditlering 
from  the  others  only  in  its  walls  being  rather  thinner.  Similar 
in  kind  to  this  was  a  cyst  described  by  Scanzoni,^  which  had 
slowly  developed  itself  till  it  had  attaitied  the  size  of  a  pigeon's 
egg.  It  had  probably  been  many  years  in  course  of  development, 
for  the  patient  had  long  experienced  pain  in  sexual  intercourse, 
referred  to  the  situation  of  the  cyst,  and  this  pain  at  last  became 
so  severe  as  to  render  the  act  impracticable.  The  tumor  was 
seated  at  the  right  side  and  anterior  part  of  the  vagina ;  it  was 
very  sensitive,  tense,  but  yet  yielded  a  sense  of  fluctuation.  The 
mucous  membrane  covering  it  and  in  its  immediate  neighborhood 
was  very  red,  and  there  was  abundant  secretion  from  the  vagina. 

'  Zeiischrift  f.  Rationelle  Medizin,  1849,  vol.  vii,  p.  1. 
2  Op.cit.,  p.  470. 


CYSTS    OF    THE    VAGINA.  511 

The  cyst  was  opened,  and  an  ounce  of  transparent  serous  fluid 
was  let  out  from  its  interior,  which  was  felt  to  be  lined  by  a  smooth 
membrane.  Injections  of  a  solution  of  nitrate  of  silver  were  made 
into  the  cyst  for  fourteen  days,  in  order  to  prevent  any  re  collection 
of  the  fluid,  and  apparently  with  good  effect;  for  six  months  after- 
wards no  trace  of  the  tumor  could  be  detected.  Almost  identical 
with  this  was  the  history  of  the  patient  in  my  second  case.  She 
was  a  married  woman,  as^cd  thirty  three,  who  for  some  seven  years 
had  been  aware  of  the  i)ro.sence  of  a  swelling  about  the  size  of  an 
egg,  which,  though  not  painful,  was  yet  the  cause  of  inconvenience 
in  sexual  intercourse,  while  besides  she  had  more  or  less  aching 
about  the  vulva,  and  for  six  months  had  suffered  from  frequent 
desire  to  pass  water  and  from  pain  in  micturition.  The  situation 
and  appearance  of  the  swelling  were  such  as  immediately  to  sug- 
gest the  suspicion  that  it  was  a  procident  bladder,  and  it  was  only 
after  the  introduction  of  a  catheter  that  this  was  ascertained  not 
to  be  the  case.  It  was  of  the  size  of  an  egg,  projecting  between 
the  labia,  and  its  surface,  from  exposure,  had  assumed  much  of  the 
character  of  ordinary  integument.  It  was  elastic,  evidently  con- 
taining fluid,  was  situated  at  the  upper  part  and  ratlier  to  the  right 
side  of  the  vulva,  springing  from  the  under  surface  of  the  right 
nynipha,  and  sufficiently  movable  to  allow  of  its  being  pushed 
back  entirely  within  the  vagina.  On  puncture,  nearly  an  ounce 
of  glairy  fluid  was  evacuated,  and  the  cavity  was  afterwards  in- 
jected with  equal  parts  of  tincture  of  iodine  and  water.  The  pre- 
vious uncomfortable  sensations  were  greatly  relieved  by  the  pro- 
ceeding, and  for  a  time  at  least  the  tumor  was  got  rid  of;  but  I 
do  not  know  whether  the  fluid  recollected. 

The  only  point  of  special  moment  connected  with  these  cysts 
regards  the  distinction  between  them  and  those  cases  in  which 
the  vaginal  wall  itself  is  prolapsed,  constituting  a  rectocele  or  a 
cystocele;  either  of  which  conditions,  when  of  long  standing,  is 
associated  with  thickening  of  the  vaginal  wall,  and  may  on  a 
superficial  examination  be  mistaken  for  a  cyst  in  these  situations. 
The  complete  disappearance  of  the  tumor  formed  by  the  j)rola})sed 
vagina  under  pressure,  and  its  increase  upon  any  effort  at  strain- 
ing, coupled  with  the  results  of  the  introduction  of  the  catheter, 
are  simple  and  conclusive  means  of  distinguishing  between  a 
swelling  produced  by  mere  vaginal  prolapse  and  one  de[»endeut 
on  the  presence  of  a  cyst  in  its  walls. 

There  is  still  much  obscurity  with  reference  to  the  mode  of 
development  of  these  cysts,  though  Virchow'  is  inclined  to  the 
opinion  that  they  originate  in  obstructed  mucous  follicles.  Such, 
no  doubt,  is  the  origin  of  those  small  superficial  subnuu-ons  cysts, 
seated  quite  low  in  the  vagina,  especially  around  the  urethra,  or  at 
the  lower  part  of  the  anterior  vaginal  wall,  of  which  M.  lluguier,- 
to  whom  we  owe  an  elaborate  essay  ou  the  subject,  also  makes 

'  Die  Krankliaftcn  Geschwulsie,  vol.  i,  247. 

*  Mimoires  de  la  Societe  de  C/drurgie  de  Paris,  vol.  i,  4to.,  lS-17,  pp.  326-:i9l. 


512  CYSTS    OF    THE    VAGINA. 

mention.  These  cysts,  wliicli  seldom  exceed  the  size  of  a  large 
pea,  and  are  often  smaller,  appear  to  he  merely  obstructed  mucous 
follicles,  since  their  walls  are  always  thin,  and  so  transparent  that 
their  contents  are  visible  through  them.  These  cysts,  with  which 
I  confess  that  I  am  not  familiar,  though  Huguier  speaks  of  them 
as  being  more  frequent  than  the  others,  seem  to  produce  no  sj-mp- 
toms,  but  to  burst  spontaneously,  or  to  give  way  during  sexual  inter- 
course, and  are  therefore  of  less  importance  even  than  the  others. 
Aly  knowledge  of  fibrous  tumors  of  the  vagina  is  ecpially  frag- 
mentary, and  indeed  I  believe  them  to  be  still  rarer  than  cysts 
connected  with  its  wall.  In  the  only  instance  that  I  have  met 
with,  the  tumor,  which  was  spherical  in  form,  did  not  exceed  the 
size  of  a  cob  nut,  gave  rise  to  no  symptoms,  and  remained  quite 
stationary  for  more  than  two  years,  during  which  period  the 
patient  was  under  my  observation.  Sometimes,  however,  tumors 
having  this  origin  acquire  a  very  considerable  size;  and  the  late 
Professor  Kiwisch^  quotes  from  a  German  journal  the  history  of  a 
case  in  which  a  tumor  weighing  more  than  ten  pounds  sprang  by 
a  pedicle  of  two  fingers'  bieadth  from  the  posterior  vaginal  wall, 
two  inches  from  the  orifice  of  the  canal.  Tumors  of  this  large  size, 
however,  are  possibly  fibro-ctllular,  rather  than  strictly  s})eaking 
fibrous  growths,  and  spring  originally  not  from  the  substance  of 
the  vaginal  wall  so  much  as  from  the  cellular  tissue  around  it, 
but  naturally  grow  as  they  increase  in  size,  in  that  direction  where 
they  encounter  the  least  resistance,  and  thus  come  at  last  to  as- 
sume the  iip]»earance  of  pedunculated  tumors  of  the  vagina.  Such 
is  probably  the  nature,  and  will  most  likely  be  the  progress,  of  a 
tumor  in  a  patient  who  was  under  my  care  in  June,  1857,  in  St. 
Bartholomew's  Hospital.  She  was  33  years  old,  had  been  married 
eight  years,  and  a  year  after  marriage  had  given  birth  to  her  only 
child.  She  professed  to  have  suffered  habitually  from  some  degree 
of  dysuria,  which  had  been  aggravated  after  her  marriage;  but  in 
August,  1856,  had  suddenly  become  so  much  worse,  after  sujipres- 
sion  of  the  catamenia,  from  catching  cold,  that  the  use  of  the 
catheter  became  necessary,  and  liad  at  intei-vals  been  required 
since.  Her  urine,  on  admission,  was  turbid  and  mixed  with 
blood,  but  her  general  health  was  good,  and  the  dysuria  almost 
disappeared  under  the  influence  of  rest  and  very  simple  treat- 
ment in  the  hospital.  The  cause  of  her  symptoms  seemed  to  be 
a  tumor,  about  three  fingers  broad,  somewhat  oval  in  form,  but 
with  its  larger  end  towards  the  uterus,  and  which  lay  in  the  direc- 
tion of  the  urethra.  This  tumor  was  firm,  but  with  some  degree 
of  elasticity;  its  surface  was  smooth,  and  it  was  not  tender  on 
pressure.  Behind  it,  and  driven  quite  into  the  posterior  part  of  the 
pelvis,  was  the  healthy  uterus,  which  had  no  connection  with  it 
whatever.  The  introduction  of  the  catheter  was  attended  by  some 
difiBculty,  and  the  instrument,  in  entering  the  bladder,  passed 
much  to  the  left  side.     jS'ow,  supposing  this  tumor  to  increase,  as 

1  Op.  cit.,  Tol.  ii,  p.  560. 


FIBROUS    TUMORS    OF    THE    VAGINA.  513 

it  doubtless  will,  it  is  in  the  direction  of  the  vagina  that  it  will 
encounter  the  least  resistance ;  thither  it  will  therefore  grow,  and 
there  it  will  probably,  in  course  of  time,  present  itself  as  a  poly- 
poid tumor.  Such,  doubtless,  was  the  history  of  the  growth  of  a 
tumor  which  Mr.  Paget^  has  described,  and  which  I  had  the  op- 
portunity of  seeing  with  him.  It  sprang  originally  from  the  right 
side  of  the  vagina,  and  the  patient  had  been  aware  of  its  existence 
for  between  three  and  four  years,  though  she  had  sought  for 
medical  advice  on  account  of  it  only  within  the  previous  twelve- 
month. One  physician  whom  slie  consulted  took  it  for  an  abscess, 
and  punctured  it;  another  recommended  the  employment  of  some 
support.  It  had  not  protruded  beyond  the  external  parts  till  some 
ten  days  before  its  removal  by  Mr.  Paget,  at  which  time  it  hung 
beyond  the  vulva  as  a  mass  five  inches  in  diameter,  of  a  somewhat 
pyriform  shape,  connected  by  a  pedicle,  an  inch  and  a  half  long 
and  of  the  same  thickness,  with  the  right  wall  of  the  vagina,  and 
the  tissues  beneath,  just  behind  the  right  nympha,  which  was  as 
it  were  arched  over  the  uj^per  part  and  right  side  of  the  neck  or 
pedicle  of  the  tumor.  Its  removal  was  accomplished  with  very 
little  loss  of  blood ;  and  the  pedicle  was  found  to  pass  by  the 
outer  wall  of  the  vagina,  in  the  loose  tissue  between  it  and  the  ra- 
mus of  the  pubes,  and  reached  nearly  two  thirds  of  the  way  to  the 
uterus.  The  characters  of  the  tumor,  as  minutely  described  in 
Mr.  Paget's  own  notes,  with  a  copy  of  which  he  favored  me,  were 
just  those  of  the  fibro-cellular  outgrowth,  which  is  apt  in  all  situ- 
ations to  attain  a  size  such  as  the  firm  fibrous  tumor  less  often 
reaches,  and  is  alwaj's  much  slower  in  acquiring. 

The  subject  oi  malignant  disease  of  the  vagina  has  been  already 
in  a  measure  anticipated  in  the  remarks  made  upon  uterine  cancer. 
I  am,  however,  inclined  to  think  that  the  rarity  of  primitive  cancer 
of  the  vagina  has  been  to  some  degree  exaggerated;  and  although 
the  main  features  of  the  disease  are  the  same  as  when  it  takes  its 
point  of  departure  from  the  womb  itself,  there  are  yet  some  reasons 
on  account  of  which  it  deserves  a  separate  notice.  Cancerous 
disease  of  the  vagina,  consequent  on  similar  affection  of  the  uterus, 
begins  for  obvious  reasons  at  tlie  upper  part  of  the  vaginal  canal, 
and  travels  thence  downwards,  involving  in  general  the  anterior 
more  than  the  posterior  wall.  Primitive  cancer  of  the  vagina  does 
not  show  the  same  predilection  for  the  anterior  wall ;  nor  does  it 
in  general  seem  to  begin  at  one  spot,  and  thence  extend;  but,  for 
the  most  part,  cancerous  infiltration  takes  place  into  the  whole  of 
one,  or  more  often  of  both  walls  of  the  vagina  simultaneously, 
and  is  at  least  as  obvious  near  the  vulva  as  in  the  neighbor- 
hood of  the  uterus.  To  this  rule,  which  obtains  in  all  instances 
of  fungoid  cancer  of  the  vagina  (and  they  are  by  far  the  more 
numerous,  since  to  that  class  may  be  referred  15  out  of  10  oases 
of  which  I  have  a  record),  the  epithelial  variety  of  the  disease 

'  Oy>.  clt..,  vol.  ii,  p.  115, 
33 


514  MALIGNANT    DISEASE 

forms  an  exception  ;  for  in  that  the  mischief  seems  to  begin  at 
one  circumscribed  spot,  not  in  the  vicinity  of  the  uterus,  and,  as 
far  as  my  experience  goes,  in  the  posterior  wall;  and  to  extend  to 
the  subjacent  tissues  and  to  pass  into  the  state  of  ulceration,  while 
as  yet  the  womb  is  quite  unatt'ected,  and  apparently  healthy  tissue 
is  to  be  found  both  above  and  below  the  seat  of  mischief 

The  following  statements  embody  the  chief  results  that  are 
deducible  from  the  cases  to  which  1  have  referred: 

In  15  instances  the  disease  was  fungoid;  in  4  epithelial.  In  1 
case  only  the  disease,  which  was  fungoid,  was  limited  to  the  an- 
terior wall ;  and  in  1  of  fungoid  cancer,  the  right  side  of  the  vagina 
only  was  atiected  when  I  saw  the  patient,  though  the  disease, 
doubtless,  extended  afterwards. 

In  6  cases,  of  which  2  were  fungoid  and  4  were  epithelial,  the 
disease  was  limited  to  the  posterior  wall.  In  the  fungoid  cases 
the  posterior  uterine  lip  also  was  aftected ;  in  the  epithelial,  the 
uterus  was  free,  though  in  one  instance  the  os  uteri  began  to  be 
red,  spongy,  abraded,  and  bleeding,  yet  I  think  not  cancerous. 

In  11  cases,  all  of  which  were  instances  of  fungoid  disease,  both 
vaginal  walls  were  involved.  In  2,  however,  the  anterior  wall  was 
chiefly  atiected. 

In  2  of  these  cases  the  contraction  of  the  vagina  prevented  the 
uterus  from  being  reached. 

In  1  case  there  was  an  outgrowth  from  the  interior  of  the  uterus, 
and  in  1  a  granular  state  of  the  anterior  lip,  the  nature  of  which 
was  doubtful. 

Or,  in  other  words,  in  6  cases  the  uterus  was  perfectly  healthy; 
in  2  it  could  not  be  reached;  in  2  the  afiection  of  the  uterus  was 
slight,  and  its  nature  not  quite  certain;  in  9  it  was  the  seat  of 
decided  cancerous  disease. 

With  reference  to  the  circumstances  which  favor  its  occurrence, 
cancer  of  the  vagina  seems  to  conform  to  the  same  rules  as  in- 
fluence the  development  of  uterine  cancer;  except,  perhaps,  that 
it  appears  to  come  on  at  a  later  period  of  life  than  cancer  of  the 
womb;  for  only  7  of  the  19  cases  were  observed  between  the  ages 
of  35  and  50;  and  the  remaining  12  between  the  ages  of  50  and 
66.  As  with  cancer  of  the  womb,  so  also  with  that  of  the  vagina, 
marriage  and  childbearing  apparently  favor  its  production  ;  for 
only  1  of  the  19  patients  w^as  unmarried;  wliile  the  remaining  18 
had  been  pregnant  95  times,  and  had  given  birth  to  86  children; 
or,  in  other  words,  there  were  5.3  pregnancies  and  4.7  labors  at 
the  full  period  to  each  marriage. 

Beyond  the  evidence  furnished  by  these  data  of  the  general 
conformity  of  vaginal  cancer  to  the  same  laws  as  govern  the  de- 
velopment of  cancer  of  the  uterus  itself,  I  do  not  know^  that  the 
conclusions  are  of  much  moment.  The  same  similarity,  however, 
between  the  two  forms  of  disease,  obtains  also  betw^een  its  symp- 
toms, whichever  be  the  situation  that  it  occupies,  and  the  duration 
of  the  afiection  appears  to  be  about  the  same  in  both  instances. 


OF    THE    VAGINA,  515 

The  early  symptoms  very  closely  resemble,  as  tliis  table  shows, 
those  which  attend  the  commencement  of  uterine  cancer. 

The  first  symptom  was  pain, in  4  cases. 

"  "  iiemorrhuge  without  pain,     .  "6      " 

a  <i  u  ^vitij  u        .  '<  6      " 

"  "  pain  and  discharge,      ...  "1      " 

"  "  discharge  without  pain,   .     .  "2      " 

19 

Pain  seems  to  be  rather  more  frequent  as  an  early  symptom 
than  when  the  disease  begins  in  the  uterus  ;  and  pain  refei-red 
to  the  back,  increased  by  defecation  or  micturition,  is  also  of  very 
common  occurrence  througliout  tlie  disease.  The  pain  seems  of  a 
more  abiding  kind  tlian  that  of  uterine  cancer,  though  in  a  large 
proportion  of  instances  the  severe  paroxysms  of  suffering,  due  no 
doubt  in  great  measure  to  uterine  action  being  excited  by  the  ad- 
vance of  disease  in  the  womb,  are  absent.  The  reason  for  this  is 
furnished  by  the  fact  that  vaginal  cancer  may  run  its  course  to  its 
fatal  issue  without  the  womb  being  at  all  implicated,  thougli  there 
is  unquestionably  a  general  disposition  both  to  the  extension  of 
mischief  by  contiguity  to  the  uterus,  and  also  to  the  occurrence  of 
secondary  though  independent  aflection  of  that  organ. 

Perforation  of  the  rectum,  or  of  the  bladder,  is  not  of  such  fre- 
quent occurrence  in  this  disease  as  might  beforehand  be  anti- 
cipated, though  the  action  both  of  the  bowels  and  of  the  bladder 
is  commonly  more  or  less  diiRcult  and  painful ;  and  the  atfection 
of  the  urethra,  which  sometimes  takes  place  in  fungoid  cancer  of 
the  anterior  vaginal  wall,  may  render  the  evacuation  of  the  bladder 
not  only  diflSicult  but  impossible. 

The  practical  conclusions  to  be  drawn  with  reference  to  this 
form  of  disease  are  somewhat  of  the  following  kind.  That  it 
occurs,  though  less  often,  yet  in  the  same  circumstances  as  uterine 
cancer,  showing  the  same  predilection  for  the  married  over  the 
unmarried,  and  for  those  who  have  been  frequently  pregnant  over 
the  sterile.  Its  general  symptoms  seem  also  to  be  similar,  except 
that  mere  painless  hemorrhage  is  somewhat  rarer  than  in  uterine 
cancer, — a  circumstance  for  which  the  seat  of  the  disease  in  vaginal 
cancer  probably  atfords  a  sufHcient  explanation.  The  progress  of 
the  disease  ap[>ears  in  both  instances  to  be  analogous;  the  can- 
cerous cachexia  is  developed  in  the  one  case  as  in  the  other,  the 
advance  of  the  evil  is  equally  rapid,  and  the  disposition  to  secondary 
deposits  at  least  as  decided  in  fungoid  disease  of  the  vagina  as  in 
fungoid  disease  of  the  womb. 

Tlicre  is  but  little  to  observe  with  reference  to  treatment,  ex- 
cept that  the  topical  palliatives  which  are  of  use  in  uterine  cancer 
are  obviously  of  more  dithcult  application  when  the  disease  is 
seated  in  the  vagina.  The  only  gleam  of  hope  that  brightens  the 
case  of  a  patient  with  malignant  disease  of  the  vagina  is  afforded 
in  those  instances  where  the  affection  is  o\'  the  eitithelial  kind. 
The  similarity  of  structure  between  the  vagina,  vulva,  and  ex- 


516  CANCER    OF    THE    VAGINA. 

ternal  parts  shows  itself,  as  lias  beeu  so  well  pointed  out  by  M. 
Ilnguier/  in  the  similarity  of  the  diseases  by  which  they  are  at- 
tacked. There  is,  therefore,  some  hope  that  ulcerated  growths  of 
the  epithelial  kind  about  the  vagina  may  be  found  to  belong  to 
the  class  of  lupus,  or  rodent  ulcer,  rather  than  to  the  more  utterly 
hopeless  category  of  diseases  which  are  intimately  allied  with 
cancer,  and  that  local  treatment  may  not  be  so  thoroughly  fruit- 
less as  experience  has  too  amply  proved  it  to  be  in  the  case  of 
malignant  disease  of  the  womb.  But  hope  even  derived  from  this 
source  is,  I  fear,  but  too  often  doomed  to  be  illusive ;  for,  on  the 
one  hand,  the  position  of  the  disease  not  only  renders  surgical  in- 
terference extremely  dithcult,  but  in  all  the  cases  which  have  come 
under  my  notice,  the  mischief  has  extended  too  deep  into  the 
submucous  tissue  for  it  to  be  possible  to  dissect  ofl'  the  diseased 
structure  from  the  subjacent  tissues.  On  the  other  hand,  the  pain 
attendant  on  the  introduction  of  the  speculum  generally  renders 
any  attempt  at  the  continuance  of  the  local  treatment  abortive. 
Some  time  since  a  case  was  under  my  care  that  seemed  favorable 
for  local  treatment.  A  long  strip  of  raised,  red,  large  granulations 
extended  for  nearly  an  inch  in  breath  and  two  in  length  along 
the  left  and  posterior  wall  of  the  vagina  up  to  its  roof,  but  leaving 
some  quarter  of  an  inch  of  healthy  tissue  between  it  and  the  neck 
of  the  womb.  Mr.  Paget,  who  was  good  enough  to  see  the  patient 
with  me,  was  in  hopes,  from  the  absence  of  thickening  about  the 
parts,  that  the  disease  might  be  classed  rather  with  rodent  ulcer 
than  with  true  carcinoma;  and  accordingly  we  determined  to  ap- 
ply the  nitrate  of  mercury  to  the  affected  surface.  The  results  of 
this  proceeding  were,  for  a  time,  most  encouraging;  and  though 
the  introduction  of  the  speculum  caused  pain  which  lasted  for 
many  hours,  yet  the  patient  gladly  submitted  to  a  plan  of  treat- 
ment, the  benefits  of  which  she  experienced  in  the  diminution  of 
the  previously  profuse,  offensive,  blood-stained  discharge,  in  the 
mitigation  of  the  backache,  and  the  improvement  of  her  general 
health.  Three  or  four  applications  of  the  acid  produced  the  com- 
plete cicatrization  of  all  but  just  that  part  of  the  disease  which 
affected  the  roof  of  the  vagina.  In  that  situation,  however,  the 
application  of  the  caustic  was  extremely  difficult,  and  there  the 
mischi?if  spread.  De}tosits  took  place,  thickening  the  vaginal  wall, 
the  granulations  grew  larger,  bled  more  readily,  and  extended 
close  up  to  the  side  of  the  cervix  uteri,  between  which  and  the 
diseased  stuctures  an  interval  no  longer  existed  ;  and  thus  treat- 
ment was  baffled,  hope  was  lost,  and  we  were  driven  once  more  to 
recognize  the  very  narrow  limits  that  circumscribe  our  power  to 
heal.  The  patient  left  the  hospital,  and  died  painfully  a  few 
months  afterwards;  and  I  do  not  know  that  her  life  could  be  said 
to  have  been  prolonged  by  the  local  treatment,  though  unques- 
tionably it  was  for  a  short  time  brightened  by  a  hope  which, 
though  illusive,  yet  cheated  her  only  of  some  suffering  and  some 
sorrow. 

1  Memoires  de  I'Academie  de  Medecine,  vol.  xiv,  1849,  p.  500. 


INFLAMMATION    OF    COWPER'S    GLAND.  517 

LECTURE   XXXIII. 

DISEASES  OF  THE  EXTEKNAL  ORGANS  OF  GENERATION. 

Inflammatory  AFFECTIONS.  Inflammationof  the  labia,  its  oonnoction  with  ob- 
litfTution  of  duct  of  Cowpcr's  gland  ;  description  of  the  gland  ;  mode  in  which 
inflammation  occurs  in  it. 

FuruncLilar  inflammation. 

Eczema.  Prurigo,  its  rarity.  Pruritus  generally  independent  of  it ;  causes  and 
treatment  of  pruritus. 

Inflammation  of  Follicles  of  Vulva. 

HYPKRiESTHESiA  OF  EXTERNAL  ORGAN.s.  Vaginal  Spasm,  or  Vaginismus.  Coc- 
cygodynia,  or  pain  about  coccyx.  Remarks  on  Masturbation,  and  excision  of 
clitoris  for  its  cure. 

Ulcerative  affections.  Tertiary  Syphilis  ;  difficulties  of  its  diagnosis.  Lu- 
pus;  its  characters,  its  relation  to  epithelial  cancer.  Case  in  illustration. 
Treatment. 

Malignant  Disease,  generally  assumes  form  of  Epithelial  Cancer,  its  sj-mptoms 
and  course.     Importance  of  early  removal. 

The  arbitrary  line  of  demarcation  which  in  this  country  separates 
the  province  of  the  physician  from  that  of  the  surgeon  has  limited 
my  experience  both  in  private  and  in  hospital  practice  with  refer- 
ence to  the  diseases  of  the  external  organs  of  generation.  If,  indeed, 
we  leave  out  of  consideration  such  as  are  the  result  of  syphilitic 
infection,  the  remainder  of  these  ailments  are  by  no  means  of  fre- 
quent occurrence,  nor  in  general  of  very  great  importance. 

Of  Inflammation  of  the  labia,  nymphce,  and  external  organs,  ex- 
cept as  an  accompaniment  of  vaginitis,  I  have  seen  almost  nothing, 
and  of  the  unhealthy  erysipelatous  infiammation  of  those  parts, 
which,  occurring  in  the  ciiild,  is  apt  to  pass  into  a  state  o\' slough- 
ing, I  have  seen  very  little.  Indeed,  notwithstanding  that  for 
more  than  five-and-twenty  years  I  have  been  coimected  with  large 
institutions  for  the  diseases  of  children,  I  have  met  with  but  three 
or  four  instances  of  its  occurrence,  and  only  one  of  diphtlieritic  in- 
flammation of  the  labia  and  nymphre.  The  circumstances  in  which 
either  of  these  affections  occurs  do  not  seem  to  be  as  commonly 
met  with  in  this  country  as  in  some  parts  of  the  continent;  while 
they  both  appear  to  belong  to  the  class  of  blood  diseases  rather 
than  to  be  purely  local  ailments  such  as  come  more  strictly  within 
the  scope  of  these  lectures. 

The  inflammation  of  the  labia  attendant  on  vaginitis,  more 
particularly  on  that  form  of  it  which  is  dependent  on  gonorrha'a, 
sometimes  extends  to  the  cellular  tissue  on  one  or  other  side,  and 
ends  in  the  formation  of  abscess.  For  the  most  part,  however, 
abscesses  in  the  labia  are  not  the  result  of  diffuse  inflammation, 
but  o^  inflammation  seated  in  one  of  those  glands  whicli  are  known 
by  the  name  of  Duverney's,  Bartholin's,  or  Cowpcr's  glands.'  They 

1  Like  some  old  discoveries,  so  that  of  the  existence  of  these  glands,  first  found 
by  Duvernoy  in  the  cow,  and  aft"r\vards  by  Hartholin  in  the  human  female,  became 
forgotten  after  Haller  had  sought  for  them  in  vain.     Mr.  Guthrie,  in  his  work  on 


518  INFLAMMATION    OF    COWPER'S    GLAND. 

are  situated  one  on  either  side  of  the  entrance  of  the  vagina,  in 
that  triangular  space  bounded  by  the  orifice  of  the  vagina  on  the 
one  side,  the  ascending  ramus  of  the  ischium  on  the  other,  and 
the  transversalis  perinagi  muscle  on  the  third,  and  are  covered  by 
the  superficial  perineal  fascia,  and  by  some  fibres  of  the  constrictor 
vagina.  They  are  small  conglomerate  glands,  of  about  the  size 
of  a  bean,  and  open  by  a  narrow  duct  some  seven  or  eight  lines 
in  length  just  in  front  of  the  hymen,  or  of  the  carunculaj  myrti- 
formes,  and  secrete  that  albuminous  fluid  which  is  poured  out 
abundantly  in  sexual  intercourse. 

It  happens  sometimes  that  the  duct  of  this  gland  on  one  or  the 
other  side  becomes  obliterated,  and  tliat  the  secretion  then  accu- 
mulates within  it,  causing  it  to  form  a  small  swelling  of  the  size 
of  a  marble,  a  cob-nut,  or  somewhat  larger,  which  projects  at  the 
lower  part,  and  towards  the  inner  surface  of  the  labium.  It  may 
remain  for  some  time  in  this  condition  producing  little  inconve- 
nience, but  in  general  it  becomes  irritated  in  walking,  or  painful 
in  sexual  intercourse,  and  thus  the  case  first  presents  itself  to  our 
notice.  If  now  it  be  opened  before  inflammation  has  attacked  it, 
a  couple  of  drachms  of  a  fluid  like  the  white  of  agg  will  be  let  out, 
the  swelling  w'ill  disappear,  and  may  perhaps  never  be  reproduced, 
since  in  many  instances  the  cyst,  after  a  free  incision  has  been 
made  into  it,  becomes  obliterated.  Sometimes  though  no  consid- 
erable annoyance  has  been  produced  by  the  swelling,  inflamma- 
tion has  taken  place  in  its  interior  siifiicicnt  to  render  its  contents 
purulent,  while  in  other  cases  the  inflammation  is  not  limited  to 
the  gland  itself,  but  extends  also  to  the  adjacent  tissue.  The 
labium  then  becomes  hot,  swollen,  and  intensely  tender  and  pain- 
ful at  its  lower  part,  so  that  the  patient  is  unable  to  move  about, 
or  even  to  leave  the  recumbent  position  without  great  sufl'ering, 
while  on  its  inner  surface  the  gland  forms  an  exquisitely  painful 
prominence,  and  matter  escapes  on  a  puncture  being  made,  with 
great  and  usually  permanent  relief  to  the  patient.  It  does,  how- 
ever, now  and  then  happen  that  much  sufl'ering  is  produced  by 
the  successive  re-formation  of  these  tumors  of  Cowper's  gland  at 
intervals  of  two  or  three  months,  an  annoyance  which  can  only  be 
prevented  by  laying  the  cyst  i'reely  open,  and  j-emoving  a  portion 
of  its  wall,  or  probably  by  the  injection  of  a  solution  of  iodine 
into  its  cavity. 

The  above  condition  has  never  come  under  my  notice  except  in 
comparatively  young  women,  and  who  either  were  married  or  at 
least  were  accustomed  to  sexual  intercourse.    There  are  some  other 

Diseases  of  the  Bladder^  refers  to  them,  though  without  giving  any  exact  descrip- 
tion of  their  form  or  relations;  butit  is  to  the  venerable  Tiedemann,  of  Heidelberg, 
that  we  owe  our  present  accurate  acquaintance  with  them.  His  essay,  Von  den 
Diivenieyschen  Driisen,  «&c.,  was  published  at  Heidelberg  in  1840,  his  investigations 
having  been  begun  the  year  previouslj'.  In  1850  M.  Huguier  published  in  the 
Memoires  de  V Academic  de  Medecine,  a  description  of  these  glands,  of  which  he  be- 
lieved himself  to  have  been  the  re-discoverer  in  1841  ;  for  like  so  many  of  his 
countrj-men,  he  was  unacquainted  with  what  had  been  done,  even  in  his  own  field 
of  investigation,  beyond  the  borders  of  France. 


BOILS    AND    ECZEMA    OF    THE    VULVA.  '      519 

afFections,  however,  which  have  no  such  relation,  but  wliicli  are 
perhaps  more  frequent  in  the  middle-aged  than  in  the  young,  and 
are  at  least  as  apt  to  occur  in  the  single  as  in  the  married.  Yerj 
troublesome  boils,  slow  in  their  advance  to  suppuration,  attended 
by  much  discomfort,  occurring  two  or  three  at  a  time,  or  in  rapid 
succession  after  each  other,  fresh  crops  of  them  frecpienti}''  apjtear- 
ing  at  intervals  of  two  or  three  weeks,  sometimes  show  themselves 
on  the  outer  surface  of  the  labia.  The  patient's  attention  is  usually 
first  called  to  them  by  a  disagreeable  itching  and  smarting,  and  she 
then  perceives  a  small  pimple  or  two  with  a  hardened  base.  The, 
pimple  by  degrees  enlarges,  and  the  hardness  around  it  extends 
both  superficially  and  into  the  substance  of  the  labium  till  it  forms 
a  mass  as  big  as  a  small  hazel-nut.  It  is  not  attended  by  much 
general  swelling  of  the  labium,  and  does  not  form  a  distinct  head 
like  an  ecthymatous  pustule,  but  its  surface  continues  flat  even  at 
the  time  when,  suppuration  having  taken  place  in  it,  a  small 
quantity  of  matter  is  discharged,  after  which  the  hardened  spot 
gradual I3'  disappears. 

The  only  local  treatment  which  has  seemed  of  much  service  in 
this  troublesome  ailment  consists  in  the  free  application  of  the 
nitrate  of  silver  while  the  boils  are  still  in  the  papular  state.  If 
done  efiectually,  this  often  prevents  the  fui'ther  progress  of  the 
pim})le,  and  spares  the  patient  much  of  that  sufi'ering  which  fo- 
mentntions,  poultices,  and  all  other  surgical  appliances  at  a  later 
period  do  but  very  imperfectly  mitigate.  There  is  no  general 
treatment  which  will  prevent  their  formation  any  more  than  that 
of  boils  elsewhere;  but  as  their  occurrence  seems  sometimes  con- 
nected with  that  irritation  of  tlie  sexual  system  wliich  oiten  ac- 
companies the  final  cessation  of  the  menses,  we  are  in  such  cases 
furnished  with  an  indication  to  guide  us  worth  bearing  in  re- 
membrance. 

^One  of  the  most  troublesome  affections  of  the  external  organs 
is  eczema  of  the  vulva,  which  is  apt  to  run  a  very  chronic  course, 
and  to  prove  extremely  intractable.  For  the  most  })art  the  ailment 
appears  in  the  flexures  between  the  thighs  and  the  labia,  whence 
it  extends  to  the  labia  themselves,  and  afterwards,  as  it  becomes 
chronic,  to  the  nymph[c,  while  it  is  not  infrequently  associated 
with  eczema  about  the  margin  of  the  anus,  and  extending  along 
the  perineum.  In  its  acute  stage  it  presents  no  difference  from 
eczema  in  other  parts  of  the  body,  but  it  seldom  remains  long  in 
that  condition,  passing  rapidly  into  a  chronic  state.  In  this  state 
the  labia  are  apt  to  lose  the  hair  which  naturally  besets  them,  and 
they  waste  from  removal  of  the  fat  which  gives  them  their  ro- 
tundity, while  the}'  and  the  nymphjTa  become  covered  with  a  thick, 
hard,  white  epithelium,  and  the  mucous  membrane  on  their  inner 
surface  becomes  dry,  unlubricated,  harsh,  and  unyielding.  It  is 
not  usual  for  this  disease  to  affect  the  vulva,  generally,  but  in- 
stances in  wliich  it  has  done  so  have  come  under  my  notii-e,  the 
mucous  membrane  entirely  losing  its  natural  appearance,  the  dry, 
harsh,  and  thickened  condition  of  the  orifice  of  the  vagina  being 


520     *  BOILS    AND    ECZEMA    OF    THE    VULVA. 

associated  with  a  marked  narrowing  of  its  calibre.  In  the  worst 
cases,  too.  the  disease  involves  the  prteputium  clitoridis  to  such  a 
degree,  that  its  thickened  indurated  tissue  projects  between  the 
labia,  while  where  the  opposing  surfaces  are  in  contact  they  con- 
tinue red,  abraded,  and  just  in  the  condition  of  parts  affected  by 
acute  eczema.  It  is  noteworthy,  also,  that  in  two  instances  of 
severe  chronic  eczema,  a  vascular  tumor  of  considerable  size  grew 
from  within  the  orifice  of  the  urethra,  but  I  do  not  know  which 
of  the  two  was  of  the  longer  standing. 

Those  slight  attacks  of  eczema  to  wliich  some  women  are  liable 
at  the  return  of  a  menstrual  period,  from  over-walking,  or  from 
similar  causes,  are  often  much  relieved  by  the  frequent  applica- 
tion of  a  glycerine  lotion,^  while  the  parts  where  the  eruption  has 
been  wont  to  appear  may  be  afterwards  rendered  less  irritable  by 
the  employment  of  pure  glycerine  or  of  zinc  ointment.  If  the 
inflammation  is  severe,  and  the  discharge  from  the  surface  abun- 
dant, the  patient  must  remain  in  bed,  and  the  continued  api)lica- 
tion  of  an  oxide  of  zinc  lotion,'^  will  both  restrain  the  secretion 
and  abate  the  soreness,  while  afterwards  the  ablution  of  the  parts 
with  thin  starch,  and  the  keeping  them  constantly  covered  with 
the  benzoated  zinc  ointment  (a  compound  which  has  the  advan- 
tage of  not  readily  becoming  rancid),  seldom  fails  to  bring  about 
very  speedy  relief 

It  is,  however,  the  chronic  form  of  eczema,  attended  with  the 
desquamation  of  dry  scales  of  epidermis  that  is  most  troublesome 
to  cure,  or  even  to  relieve.  I  have  observed  it  in  its  severest 
forms  only  in  hospital  patients,  and  these  it  was  almost  impossi- 
ble to  induce  to  remain  long  enough  for  more  than  some  measure 
of  alleviation  of  their  ailment  to  be  obtained.  The  distressing 
itching  was  in  most  instances  relieved  for  a  time  by  smearing  the 
parts  with  cod-liver  oil.  The  relief  which  this  afforded,  however, 
was  but  temporary,  and  other  unctuous  applications  answered  the 
same  end,  also,  only  for  a  time,  and  in  general  less  effectually. 
Indeed  nothing  short  of  completely  modifying  the  state  of  the 
skin  by  caustic  applications  seemed  in  these  cases  to  hold  out  any 
prospect  of  cure.  I  have  for  this  purpose  employed  the  solid  ni- 
trate of  silver,  substituting  for  it,  as  fresh  and  more  delicate  epi- 
dermis was  produced,  a  solution  of  twenty  grains  of  the  salt  to  an 
ounce  of  distilled  water.  Professor  Scanzoni'^  uses  with  the  same 
object  a  solution  of  half  a  drachm  of  caustic  potass  in  an  ounce  of 
distilled  water,  which  is  to  be  lightly  applied  b}'  means  of  a  camel's 
hair  ])encil,  and  advises,  besides,  as  the  disease  abates,  very  copious 
and  frequent  ablution  with  cold  water. 

Mere  external  applications,  however,  though  essential  for  the 


1  (Formula,  No.  14.) 
R.  Gh'c.  purificati,      ....     .^^ij 

Aqua3  Rosse, ^vj 

M.  ft.  Lotio. 


2  (Formula,  No.  15.) 

R.  Zinci  Oxydi, ,:^ij 

Mist.  Aciicise, .^i 

Aquie  Rosaj,        ^v 

M.  ft.  Lotio. 
Op.  cit.,  p.  562. 


PRURIGO,    AND    PRURITUS    OF    THE    VULVA.  521 

patient's  relief,  and  condncino;  much  to  her  permanent  recovery, 
seldom  siithce  in  cases  of  much  severity  and  long  standino;.  In 
them,  as  in  chronic  eczema  seated  elsewhere,  a  long  continued 
course  of  arsenical  preparations  appears  to  furnish  the  only  means 
of  effecting  a  permanent  cure. 

Prurigo  is  often  spoken  of  in  connection  with  that  distressing 
itching  of  the  sexual  organs  from  which  women  frequently  suffer. 
"While  pruritus,  however,  is  a  common  affection,  prurigo  is  one  of 
very  considerable  rarity;  and  I  have  never  met  with  an  instance 
in  which  the  eruption  was  limited  to  those  parts,  though  patients 
suffering  from  general  prurigo  are  sometimes  much  distressed  by 
the  appearance  of  the  erui)tion  on  the  genitals,  while  others  are 
driven  by  the  irritation  to  scratch  themselves  to  such  a  degree  as 
to  wound  the  skin,  and  thus  produce  little  bloody  points  not  un- 
like those  wliich  one  sees  on  the  top  of  the  papillfe  of  prurigo. 
In  spite  of  this  absence  of  any  necessary  connection  between  the 
painful  itching  of  the  sexual  organs  and  the  appearance  of  any 
eruption  on  their  surface,  this  will  perhaps  still  be  the  most  con- 
venient place  for  introducing  what  I  have  to  say  concerning  it. 
Though  commonly  spoken  oli  as,  j^ruritus  of  the  pudenda  or  of  tlie 
vulva,  the  sensation  is  by  no  means  limited  to  one  part,  but  is 
sometimes  referred  to  the  external  organs,  to  the  surface  of  the 
labia,  or  to  the  mons  veneris ;  at  other  times  it  is  experienced 
about  the  nymph?e  and  the  vestibulum,  while  sometimes  it  affects 
the  vaginal  canal,  or  even  the  os  uteri.  The  circumstances  in 
which  it  is  met  with  vary  as  much  as  the  situations  to  which  the 
sensation  is  referred,  and  serve  to  show  that  in  strict  propriety 
the  ailment  deserves  to  be  classed,  as  it  is  by  some  continental 
writers,  among  the  nervous  affections  of  the  sexual  organs.  It  is 
far  from  being  an  infrequent  attendant  on  the  earlier  months  of 
pregnancy,  and  likewise  sometimes  accompanies  organic  disease 
of  the  womb,  especially  carcinoma  in  its  earlier  stages.  It  some- 
times attends,  and  still  oftener  precedes,  the  menstrual  period, 
esjteeially  in  w^omen  who  menstruate  scantily,  irregularlj',  or 
painiully ;  while  again  it  frequently  occurs  at  the  approach  of  the 
climacteric  period,  when  menstruation  has  either  finally  ceased, 
or  is  about  to  disappear.  It  accompanies  hemorrhoids,  and  is 
sometimes  one  of  the  discomforts  |)roduced  by  a  varicose  state  of 
the  veins  of  the  labia,  it  attends  the  onset  and  decline  of  most 
cases  oC  inflammation  of  the  vagina,  and,  in  short,  is  seldom  al- 
together absent  when  any  cause  whatever  produces  a  state  of  un- 
natural congestion  of  the  sexual  organs.  Now  and  then  it  is 
associated  with  a  sort  of  herpetic  eruption  of  the  inner  surface  of 
the  labia,  the  vesicles  of  which  are  apt  to  assume,  on  l)ursting, 
something  of  the  character  of  small  aphthous  sores;  but  my  own 
cxjjcrience  does  not  lead  me  to  regard  this  condition  as  at  all  of 
common  occurrence. 

To  describe  a  sensation  is  proverbially  difficult;  but  it  may  be 
observed,  that  as  this  pruritus  varies  in  degree,  so  it  does  also  in 
kind.     It  is  sometimes  an  unpleasant  sense  of  creeping  or  formi- 


522  PRURITUS    AND    OTHER 

cation,  at  other  times  a  feeling  of  smarting,  while  in  other  cases 
the  positive  itching  is  so  distressing  as  to  be  almost  unbearable. 
"Warmth  always  aggravates  it,  and  with  some  persons  it  suffices  to 
come  into  a  warm  room  in  order  to  experience  an  attack  of  it, 
while  in  the  case  of  most  patients  the  nights  are  in  great  measure 
sleepless,  because  to  lie  down  in  bed  is  at  once  a  signal  for  the 
commencement  of  the  itching.  Cold  for  a  moment  eases  it,  but 
this  relief  is  but  momentary,  and  patients  are  driven  to  scratch 
and  rub  themselves  in  order  to  obtain  a  sort  of  relief  which  con- 
sists in  the  substitution  of  a  burning,  smarting  sensation  for  the 
less  tolerable  itching.  This,  however,  not  only  does  no  real  good 
but  the  very  rubbing  of  the  parts  both  aggravates  the  patient's 
condition,  and  also  helps  to  produce  and  to  keep  up  a  state  of 
morbid  sexual  excitement,  which  in  some  of  these  cases  consti- 
tutes by  no  means  the  least  other  sufferings. 

The  treatment  obviously  depends  on  the  conditions  with  which 
this  distressing  symptom  is  associated.  The  empirical  prescrip- 
tion of  lotions,  ointments,  or  other  ap[»lications,  without  [)revious 
inquiry  as  to  the  state  of  the  uterine  functions,  is  worse  than  idle. 
One  case  I  remember  in  wliich  the  application  of  the  nitrate  of 
silver  to  a  long-standing  abrasion  of  the  os  uteri  was  followed  by 
the  almost  immediate  cure  of  a  previously  very  distressing  pruri- 
tus. When  consequent  on  vaginitis  the  cure  of  the  inflammation 
and  the  cessation  of  the  itching  take  place  almost  simultaneously, 
while  in  general  nothing  relieves  the  irritation  which  accompanies 
the  decline  of  the  vaginitis  more  than  the  Goulard  water  and 
liydrocyanic  acid,  in  the  proportion  of  two  drachms  of  the  latter 
to  eight  ounces  of  the  former.  Whenever  there  is  much  evidence 
of  congestion  about  the  external  parts,  as  shown  either  by  their 
heat,  swelling,  or  redness,  and  tenderness,  a  few  leeches  to  the 
vulva,  or  to  the  margin  of  the  anus,  will  generally  give  much  re- 
lief, and  the  same  local  leeching  is,  as  might  be  expected,  of  much 
service  when  the  pruritus  is  associated  with  hemorrhoids.  The 
herpetic  eruption  on  which  Dr.  Dewees,  of  Philadelphia,  laid  so 
much  stress  as  a  cause  of  this  ailment,  is  relieved — as  arc  other 
cases  where,  without  any  disposition  to  the  formation  of  vesicles 
or  of  little  aphthous  ulcers,  much  heat  and  redness  of  the  parts 
exist — by  a  lotion  of  borax  and  morphia,^  which  indeed  has  proved 
more  generally  serviceable  in  my  hands  than  any  single  remedy 
besides. 

In  those  cases  in  which  there  is  any  local  inflammation,  or  con- 
siderable congestion  present,  unctuous  applications  do  not  in 
general  do  much  good.  In  others  in  which  this  condition  does 
not  exist,  or  has  been  completely  removed,  the  employment  of  a 
liniment  of  half  a  drachm  of  chloroform  to  an  ounce  of  olive  oil, 

'  (Formula  No.  16.) 

R.  Soda  Subboracis, ^iv. 

Morphise  Hydrochlor, jjr.  viij. 

Aquae  Rosae, Jx. 

M.  ft.  Lotio. 


NEURALGIC    AFFECTIONS    OF    VAGINA    AND    VULVA.        523 

both  externally  and  to  the  vaginal  walls,  which,  I  believe,  Scan- 
zoni  was  the  first  to  recommend/  is  often  of  great  service.  The 
pure  cod-liver  oil,  also,  often  relieves  the  external  irritation,  though 
I  suspect  chiefly  in  those  cases  in  which  there  is  an  approach  to  a 
state  of  chronic  eczema ;  while  Dr.  Rigby,  in  his  recent  work, 
strongly  advocates  an  ointment  of  equal  parts  of  cod-liver  oil  and 
red  precipitate  ointment  as  successful  in  cases  which  have  proved 
rehellious  to  other  means. 

Two  other  remedies  have  sometimes  done  good  service  in  cases 
of  f)bstinate  pruritus  ;  one  of  these  is  quinine,  which,  given  in  two- 
grain  doses  every  six  hours,  has  in  some,  I  fear  exceptional  in- 
stances, appeared  to  me  to  relieve  this  as  it  does  other  neuralgic 
affections.  The  other  remedy  is  belladonna,  which  both  out- 
wardly employed  and  internally  administered,  has  often  proved 
extremely  useful.  I  generally  give  the  belladonna  in  the  ibrm  of 
pills  and  combined  with  camphor,  beginning  with  half  a  grain  of 
the  extract  to  three  grains  of  camphor,  and  increasing  the  bella- 
donna until  dimness  of  vision,  or  sense  of  dryness  in  the  throat  is 
produced.  At  the  same  time,  I  direct  an  ointment  of  a  scruple 
of  the  extract  of  belladonna  to  half  an  ounce  of  spermaceti  oint- 
ment and  half  an  ounce  of  glycerine,  to  be  smeared  twice  a  day 
over  the  surface,  and  the  relief  which  these  measures  obtain  has 
not  seldom  outlasted  their  employment  and  proved  to  be  per- 
manent. 

There  still  remains  the  employment  of  the  nitrate  of  silver, 
either  externally  or  to  the  vaginal  walls,  according  to  the  seat  of 
irritation;  but  I  have  not  myself  had  recourse  to  it;  for  either 
other  remedies  have  relieved  the  ailment,  or  it  has  -ceased  with 
the  removal  of  its  cause,  as  in  cases  where  it  occurred  during  preg- 
nancy ;  or  the  patient  has  no  longer  heeded  it,  as  in  some  instances 
of  cancer,  where  other  and  worse  sutfering  has  made  the  former 
annoyance  seem  less  intolerable. 

This  is  perhaps  the  best  place  to  notice  two  painful  neuralgic 
affections,  the  one  of  the  vagina,  the  other  of  the  rectum,  which 
under  the  names  of  vaginmnus  and  coccygodynia,  have  of  late  at- 
tracted considerable  attention,  though  both  conditions  must  have 
long  been  known  practically  to  all  wlio  have  had  much  to  do  with 
the  treatment  of  the  diseases  of  women. 

The  former  condition  is  one  of  pain  and  spasm  at  the  entrance 
of  the  vagina,  so  severe  as  to  be  a  complete  bar  to  sexual  inter- 
course. The  pain,  however,  is  often  by  no  means  limited  to  the 
act  of  sexual  congress,  but  the  patient  experiences  a  sense  of  dis- 
comfort about  the  vulva,  which  is  raised  to  positive  pain  on  walk- 
ing, and  sometimes  even  on  at^suming  the  sitting  jiosture,  though 
the  degree  of  suffering  varies  much  in  different  women,  and  in 
the  same  woman  at  different  times.  If  any  attempt  is  made  to 
introduce  the  ffnger,  the  pain  at  once  becomes  intt)lera1)le,  and 
the  completion  of  the  examination  is  prevented  not  merely  by  the 

1  0;;.  ci7.,p.  545. 


524  VAGINISMUS. 

patient's  inability  quietly  to  submit  to  it,  but  by  the  violent  con- 
striction of  the  sphincter  vagiuse  which  is  at  once  produced. 

This  state  is  by  no  means  invariably  limited,  as  in  the  cases 
related  by  Dr.  Marion  Sims,'  who  first  proposed  for  it  the  name 
of  vaghiismus,  to  newly  married  persons  in  whom  intercourse  has 
been  imperfectly  accomplished,  and  in  whom  the  hymen  has  been 
but  partially  obliterated.  I  have  seen  it  in  its  less  extreme  degrees, 
left  behind  after  chronic  uterine  inflammation,  and  have  observed 
that  in  some  cases  long  after  the  introduction  of  the  fine-er  or  even 

• 

of  a  speculum,  could  be  borne  without  suffering,  the  act  of  coitus, 
no  doubt  owing  to  the  peculiar  excitement  of  the  nervous  system 
which  attends  it,  was  so  painful  as  to  be  altogether  impossible. 

I  have  never  seen  it  as  an  isolated  symptom  in  patients  other- 
wise altogether  healthy,  but  have  always  observed  it  to  be  asso- 
ciated with  other  nervous  and  hysterical  symptoms,  with  dysmenor- 
rhcea,  often  with  pain  in  defecation  and  micturition  ;  and  like  all 
ailments  of  this  class,  its  severity  is  liable  to  great  and  apparently 
causeless  variation.  Allied  to  this  condition,  too,  is  the  intense 
pain  in  micturition  which  I  have  occasionally  observed  in  un- 
married women,  and  which  I  have  seen  baffle  all  kinds  of  treat- 
ment. Of  this  a  most  striking  instance  came  under  my  notice  in 
a  young  unmarried  lad}'  about  24  years  old,  in  whom  it  had  been 
gradually  coming  on  almost  from  the  very  time  of  puberty.  She 
was  pale,  delicate,  and  thin,  but  had  no  other  positive  ailment  than 
the  agony  which  attended  every  act  of  micturition,  and  which  con- 
tinued for  a  quarter  or  half  an  hour  after  she  had  emptied  the 
bladder  of  urine,  which  was  found  invariably  to  be  healthy.  She 
was  seen  by  numbers  of  doctors;  she  was  sounded  for  stone  on 
more  occasions  than  one,  was  treated  by  all  imaginable  remedies; 
her  bladder  was  injected  with  sedatives,  and  with  carbonic  acid 
gas,  tonics,  large  doses  of  chalybeates,  sea-air  and  bathing,  and 
visits  to  the  German  watering-]»laces,  were  all  had  recourse  to. 
Her  general  health  at  the  end  of  these  experiments  was  no  worse, 
and  her  local  sufi'ering  no  better,  than  at  their  commencement, 
and  she  continued,  after  years  of  treatment,  a  feeble,  nervous, 
hysterical  invalid,  with  little  power  of  body  or  of  mind,  and  with 
this  one  distressing  peculiarity  only  to  distinguish  her  from  a 
hundred  others. 

^  1  do  not  think  that  a  state  of  vaginitis  is,  as  Dr.  ChurchilP  con- 
siders, usually  the  first  step  towards  the  production  of  this  vaginal 
pain  and  spasm;  and  as  I  have  known  the  state  to  supervene  in 
women  who  had  been  married  two  or  three  years  before  the  com- 
mencement of  the  symptoms  (though  never  in  any  who  had  given 
birth  to  children)  I  believe  the  conditions  in  which  it  originates 
may  be  very  various. 

The  first  essential  in  all  cases  towards  the  patient's  improve- 

1  Obstetrical  Transactions,  vol.  iii,  p.  356. 

2  Diseases  of  Women,  4th  ed.,  Dublin,  1864,  p.  123,  where  will  be  found  a  very 
good  account  of  this  condition. 


VAGINISMUS.  525 

ment  is  her  separation  from  her  husband's  bed,  and  the  complete 
cessation  of  all  attempts  at  intercourse.  Tepid  hip  baths,  soothing 
local  treatment,  and  the  removal  of  any  inflammation  of  the 
vagina  or  of  its  oriflce,  should  any  such  condition  exist,  come 
next.  The  application,  for  this  purpose,  of  a  solution  of  nitrate 
of  silver  by  a  speculum  to  the  whole  tract  of  vaginal  mucous 
membrane,  as  recommended  by  Dr.  Churchill,  implies,  however, 
that  already  considerable  progress  must  have  been  made  towards 
the  patient's  cure,  since  in  some  of  the  cases  which  I  have  seen 
the  lino^er  even  coukl  not  be  introduced  without  intense  suflerini;. 

The  removal  of  any  obvious  uterine  ailment,  and  the  improve- 
ment of  the  patient's  general  health,  are  of  course  to  be  attended 
to;  but  I  may  say  that  in  no  case  have  I  found  the  much-vaunted 
bromide  of  potass  either  abate  the  sensitiveness  of  the  sexual 
organs,  or  control  any  of  those  nervous  ailments  of  an  hj'sterical  or 
epileptiform  kind  wliich  are  commonly  supposed  to  be  associated 
with  disorder  or  excitement  of  the  sexual  system. 

The  te[)id  douche  to  the  sacrum,  and  nates  have  in  some  in- 
stances proved  of  much  service  in  my  hands;  and  I  should  expect 
the  mud  and  carbonic  acid  gas  baths  of  Meinberg  and  some  other 
places  in  Germany  to  be  useful,  though  I  have  not  had  any  oppor- 
tunity of  trying  them  in  these  cases. 

The  gradual  dilatation  of  the  orifice  of  the  vagina  by  means  of 
bougies  is  the  last  step  in  the  treatment  of  these  cases,  and  one 
which  acts  in  two  ways,  both  by  mechanically  widening  the  canal 
and  also  by  accustoming  the  vagina  to  the  presence  of  the  foreign 
body.  I  have  employed  rectum  bougies  of  difterent  sizes,  direct- 
ing the  patient  to  introduce  one  for  an  hour  daily,  exchanging  it 
as  she  was  able  for  one  of  a  larger  and  still  larger  size.  Dr.  Sims 
and  Dr.  Churchill  employ  glass  dilators,  which  have  the  advantage 
of  being  more  cleanly. 

I  have  seen  one  case  in  which  I  can  conceive  it  possible  that 
some  surgical  proceeding,  such  as  is  practised  by  Dr.  Marion  Sims, 
would  be  of  advantage,  though  in  this  instance  the  intense  vaginal 
tenderness  was  but  one  of  a  set  of  symptoms  of  most  aggravated 
hysteria.  Dr.  Sims's  operation  consists  in  the  excision  of  the  re- 
mains of  the  hymen,  the  subsequent  incision  of  the  vaginal  orifice, 
and  the  further  enlargement  of  the  canal  by  means  of  a  dilator. 
This  proceeding,  indeed,  is  somewhat  formidable,  and  is  attended 
sometimes  b}'  a  good  deal  of  hemorrhage;  but  the  condition  of 
vaginal  spasm  and  jtain  is  so  grievous  as  to  justify  almost  any 
means  being  adopted  for  its  relief 

Backache  is  so  common  an  attendant  upon  a  large  number  of 
the  diseases  of  women,  that  both  we  and  our  patients  often  pay 
but  little  heed  to  it,  and  except  in  instances  where  it  is  unusually 
severe,  make  but  lew  inquiries  as  to  its  exact  situation,  or  as  to 
the  circumstances  that  aggravate  or  relieve  it.  To  this  it  is  })rob- 
ably  due  that,  until  quite  recently,  when  Dr.  Simpson'  directed 

1  Medical  Times,  July  2,  1859. 


526      PAIN  AT  THE  COCCYX,  OR  C  OC  C  Y  GO  D  YNI  A. 

attention  to  pain  in  tlie  coccyx,  or  coccygodr/nia,  it  had  not  been 
recognized  as  a  distinct  affection. 

Usually  after  childbirth,  sometimes  after  a  fall  or  blow  on  the 
lower  part  of  the  spine,  occasionally  after  long-continued  horse 
exercise,  sometimes  as  one  of  a  train  of  symptoms  associated  with 
misplacement  or  some  other  ailment  of  the  uterus,  and  now  and 
then,  independent  of  any  obvious  exciting  cause,  women  complain 
of  pain  which  they  refer  to  the  coccyx  and  its  point  of  junction 
with  the  sacrum.  This  pain  is  experienced  in  sitting,  is  often 
very  severe  during  defecation,  is  usually  constant  and  dull,  though 
aggravated  at  intervals  without  any  apparent  cause.  It  is  relieved 
by  the  recumbent  posture,  but,  unlike  the  pain  that  accompanies 
prolapsus,  is  not  aggravated  by  walking  or  by  the  erect  posture. 
It  is  often  worse  at  the  menstrual  period,  is  considerably  aggra- 
vated by  constipation,  and  is  sometimes  rendered  very  severe  by 
sexual  intercourse. 

There  is  no  special  tenderness  of  the  lumbar  region,  or  of  the 
upper  part  of  the  sacrum  ;  but  the  lower  part  of  the  sacrum  is 
often  sensitive,  and  the  patient  directs  attention  to  the  coccyx  it- 
self as  the  point  whence  this  sensitiveness  proceeds;  and  pressure 
on  the  bone  is  found  to  be  acutely  painful.  The  pressure  of  the 
bone  upwards  causes  much  more  suttcring  than  its  pressure  back- 
ward by  the  finger  in  the  vagina  or  rectum,  and  the  sacro-coccy- 
geal  joint  is  especially  painful. 

Professor  Scanzoni/  who  has  given  by  far  the  fullest  and  best 
account  which  we  possess  of  this  affection,  states  that  9  out  of  24 
patients,  of  whose  cases  he  has  a  record,  first  complained  of  the 
pain  during  childbed;  that  6  of  these  patients  were  primiparaj, 
and  5  of  them  had  been  delivered  by  the  forceps  after  a  tedious 
and  difficult  labor.  Two  other  patients  referred  to  frequent  long 
rides  on  horseback  as  the  occasion  of  their  suffering.  In  11,  then, 
of  the  24  cases,  the  ailment  seemed  due  to  causes  calculated  to 
produce  local  injury  of  the  coccyx,  and  how  frequent  such  injuries 
must  be  receives  a  good  illustration  in  the  fact,  that  32  out  of  180 
coccyx  bones  which  the  anatomist  Ilyrtl  collected  in  two  years 
presented  evidence  of  dislocation  and  subsequent  anchylosis. 

In  many  cases,  however,  the  pain  in  the  bone  is  not  due  to  any 
traumatic  cause,  but  is  sympathetic  with  some  uterine  or  ovarian 
disease,  and  that  by  no  means  of  a  kind  to  affect  the  bone  by 
pressure,  or  in  any  mechanical  manner. 

In  these  instances  the  removal  of  the  coexistent  disease  is  ob- 
viously the  first  duty  of  the  practitioner,  and  how  important  tliis 
may  be  is  further  shown  by  a  fact  which  Scanzoni  mentions,  that 
three  women  who  had  suffered  much  in  their  younger  years  from 
this  coccygodynia,  became  completely  free  from  it  as  soon  as  men- 
struation had  completely  ceased. 

I  have  not  seen,  or  at  least  have  not  recognized  this  affection  in 

1  Op.  cit,  pp.  589-602. 


MASTURBATION,    AND    REMOVAL    OF    THE    CLITORIS.        527 

its  severer  and  more  intractable  forms.  One  of  the  worst  cases  of 
it  wliich  I  have  observed  occurred  in  a  young  unmarried  lady,  in 
connection  with  hemorrhoids  and  habitual  constipation,  and  dis- 
appeared completely  when  these  conditions  were  relieved.  Perfect 
rest,  mikl  aperients,  the  complete  emptying  the  rectum  of  all  ffecal 
matter;  leeches  to  the  coccyx,  tepid  hip-baths,  and  warm  fomen- 
tations: such  are  the  means  by  which,  in  the  majority  of  instances, 
much  relief  is  atlbrded.  If  these  means  fail,  or  if  the  pain  is  ob- 
viously neuralgic,  or  if,  though  mitigated,  it  is  not  removed  by 
this  treatment,  Scanzoni  resorts  to  the  subcutaneous  injection  of 
morphia  over  the  painful  s[)ot.  He  has  found  this  a  far  more  effi- 
cient remedy  than  any  kind  of  liniment,  ointment,  or  suppository, 
and,  unlike  Dr.  Simpson,  states  that  its  results  have  but  rarely 
disappointed  him. 

The  condition,  though  tedious,  and  apt  in  its  severer  forms  to 
relapse,  appears  to  be  tolerably  amenable  to  treatment.  Of  Scan- 
zoni's  24  cases,  10  recovered  perfectly,  9  were  much  relieved,  the 
result  of  3  which  he  saw  but  once  is  unknown  to  him,  and  in  2 
the  evil  continued  unrelieved  by  any  treatment.  Even  in  these, 
however,  the  sutfering  was  not  so  severe  as,  in  his  judgment,  to 
warrant  the  subcutaneous  division  of  the  muscles,  ligaments,  and 
fascige  connected  with  the  lowest  part  of  the  coccyx,  which  Dr. 
Simpson  has  recommended,  and  practised  with  perfect  success. 
The  object  of  the  operation  is  to  set  the  coccyx  perfectly  free  and 
perfectly  at  rest,  and,  if  other  means  fail,  should  und()ul)tedly  be 
had  recourse  to,  though  not  as  a  first  measure  and  independent  of 
previous  treatment. 

A  few  words  may  be  added  here,  better  perhaps  than  anywhere 
else,  with  reference  to  the  alleged  frequency  of  masturbation  in  the 
female  sex,  and  the  removal  of  the  clitoris  for  its  cure.  There  can 
be  no  doubt  but  that  self-abuse  is  not  limited  to  the  male  sex,  and 
that  women  sometimes  become  addicted  to  it;  and  it  must  have 
happened  to  all  practitioners  of  medicine  to  receive  occasional 
painful  confessions  from  women  who  were  unable  to  overcome  a 
vice,  indulgence  in  which  polluted  their  thought,  or  who  traced 
the  absence  of  sexual  feeling  in  married  life  to  habits  contracted 
in  their  girlhood.  Such  cases,  however,  are  by  no  means  fre([uent; 
and  it  seems  doubtful  whether  the  practice  of  masturbation  pro- 
duces such  injurious  jdiysical  effects  in  the  female  as  in  the  male 
subject,  though  it  is  im[)0ssible  to  over-estimate  its  banetul  influ- 
ence on  the  moral  feelings  and  the  sense  of  self-respect. 

If  the  habit  could  be  overcome,  if  the  mind  could  be  restored 
to  its  purity  by  any  mutilation  of  the  person,  one  would  feel  that 
no  penalty  would  be  too  great  to  pay  for  sucli  a  boon.  The  seat 
of  sexual  feeling  is,  however,  by  no  means  confined  to  the  clitoris; 
habitual  masturbation  brings  with  it  no  change  in  the  organ,  and 
it  is  not  by  irritating  it  that  some  women  who  have  sunk  to  the 
lowest  depths  earn  ibr  themselves  a  nauseous  living  by  minister- 
ing to  the  passions  of  the  most  abandoned  of  their  own  sex;  nor 


528  FOLLICULAR    INFLAMMATION 

by  removing  the  clitoris  would  the  habit  be  broken  through,  or 
the  means  of  indulging  it  removed.^ 

There  are  some  subjects  which  by  common  consent  are  little 
mentioned  among  honorable  practitioners  of  medicine,  and  the 
professed  curers  of  self-abuse  and  its  consequences  in  men,  whether 
they  advertise  themselves  by  notices  at  the  corners  of  tlie  streets, 
or  by  noisy  self-assertion,  occupy  a  position  morally  like  that  which 
his  red  cloak,  his  bell,  and  his  cry,  "Unclean,  unclean,"  gave  to 
the  leper  of  old.  They  are  seen  and  they  are  shunned.  Like 
their  prototypes,  too,  wanton  outrage  seems  to  have  for  them  a 
peculiar  attraction.  It  will,  I  imagine,  scarcely  be  contended  that 
proceedings  which  we  should  reprobate  if  practised  on  the  one 
sex  change  their  character  when  perpetrated  on  the  otlier. 

I  know  a  lady,  aged  fifty-three,  whose  ^^oungest  child  was  more 
than  twenty-years  old,  who  had  suffered  from  a  painful  fissure  of 
the  anus,  for  which  she  underwent  the  usual  operation  of  dividing 
the  mucous  membrane  of  the  ulcer.  The  surgeon  who  did  this, 
without  saying  one  word  to  the  lady  or  to  her  liusband,  or  hinting 
in  any  way  what  he  was  about  to  do,  cut  oft'  her  clitoris.  The 
stump  of  the  amputated  clitoris  became  the  seat  of  pain,  such  as 
sometimes  follows  amputation  of  a  limb,  and  for  months  the  i)atient 
was  in  a  state  of  almost  ceaseless  anguish,  which,  after  the  lapse 
of  between  two  and  three  years,  abated,  but  has  not  yet  altogether 
ceased.  In  answer  to  her  inquiries  why  some  other  operation  had 
been  performed  in  addition  to  that  which  she  knew  was  requisite, 
after  some  evasion,  she  at  length  learned  what  had  beefi  done,  and 
further,  had  the  humiliation  of  discovering  that  the  justification  of 
the  outrage  was,  that  she  was  assumed  by  the  surgeon  to  be  ad- 
dicted to  a  vice  with  the  very  name  and  nature  of  which  she  was 
alike  unacquainted. 

Our  profession  ought  to  be  a  noble  one.  The  ring  and  the 
sword  in  some  universities  of  the  continent  still  symbolize  the 
knightly  vows  taken  by  the  candidate  for  the  doctor's  degree  ; 
and  it  is  in  the  spirit  of  chivalry  alone  that  medicine  can  be  safely 
practised.  I  have  written  this  history  in  all  sadness  as  a  warning 
to  my  younger  brethren,  how  if  they  are  not  watcliful,  it  is  possi- 
ble, "  as  noblest  things  find  basest  using,"  that  they  may  pervert 
their  talents,  and  degrade  their  manhood,  till  they  sink  so  low  as 
to  find  opportunities  for  mischief  in  the  practice  of  their  art,  in- 
stead of  occasions  for  the  exercise  of  that  power  of  healing  which 
is  most  God-like. 

M.   Huguier  has  described,  with  extreme  minuteness,  in  the 

1  With  reference  to  the  absence  of  any  change  in  the  sexual  organs  in  connec- 
tion with  habitual  masturbiition,  the  .statements  of  Parent  Duchatelet  are  decisive  : 
"Thus  les  jours  on  revolt  dans  la  prison  des  prostituees  quelques  unes  de  ces  filles 
d'une  lascivet6  etfrenee,  ou  de  ces  fcmtnes,  plus  lascives  encore,  adonn^es  au  vice 
honteux  dont  j'ai  parle ;  on  examine  ces  femmes  comma  les  autres,et  jamais  eiles 
n'ont  prdsenrees  dans  leur  organisation,  la  moindre  chose  qui  les  distinguat  du 
teste  des  prostituees,  on  du  commun  des  femmes."  La  Prostitution  dans  la  Viile  de 
Paris,  Paris,  1867,  3d  ed.,  vol.  i,  p.  111. 


AND    TERTIARY    SYPHILIS    OF    THE    VULVA.  529 

Memoirs  of  the  Aoademy  of  Medicine  of  Par  is, ^  tlie  diseases  of  tlie 
sebaceous  and  piliferous  follicles  of  the  vulva,  lie  s[)eaks  of  a 
condition  of  acne  of  the  vulva,  in  which  the  contents  of  some  of 
the  sebaceous  follicles  accumulate  without  any  obvious  cause.  The 
number  of  follicles  so  affected  is  not  in  general  considerable, 
though  like  acne  of  the  face,  which  in  all  respects  it  closely  re- 
sembles, the  affection  is  extremely  chronic,  and  different  follicles 
are  apt  to  become  diseased  in  succession.  The  accumulation  of 
their  contents,  too,  sometimes  occasions  inflammation  of  the  folli- 
cles, and  then  that  disease  is  produced  which  M.  Huguier  terms 
vulvar  foUiculitis,  and  which  has  occasionally  come  under  my  ob- 
servation, though  far  less  often  than  it  and  other  ailments  of  the 
external  organs  present  themselves  to  one  who  has  so  peculiar  a 
field  as  is  furnished  by  the  Hopital  de  Lourcine.  This  affection, 
which  he  states  to  be  most  frequent  during  pregnancy,  may  occur 
also  at  other  times,  induced  by  local  irritation  of  any  kind,  and 
especially  by  habitual  want  of  cleanliness.  It  is  characterized  by 
the  appearance  in  the  fold  of  the  thigh,  on  the  outer  surface  and 
free  edge  of  the  labia,  on  the  nymphre,  and  on  the  base  of  the  prjie- 
putiuin  clitoridis,  of  little  red  rounded  papilke,  which  at  first 
scarcely  exceed  the  size  of  a  pin's  head  ;  some  of  them  are  distinct, 
while  others  are  collected  together  into  irregular  patches.  By 
degrees  these  follicles,  at  first  merely  congested  and  enlarged  by 
the  accumulation  of  their  contents,  become  more  inflamed,  a  little 
drop  of  pus  may  be  seen  at  their  apex;  they  then  usuall}'  burst 
and  shrivel,  though  sometimes  they  wither  without  having  pre- 
viously discharged  their  contents. 

The  ailment,  if  left  untreated,  is  chronic  in  its  course,  and  the 
follicles  take  as  long  as  twenty  or  thirty  days,  or  even  longer,  to 
pass  through  the  three  stages  of  eruption,  suppuration,  and  desic- 
cation, while  successive  crops  will  run  the  same  course,  and  pro- 
tract the  disease  for  weeks  or  months.  It  is,  however,  amenable 
to  very  simple  treatment,  such  as  rest,  cleanliness,  baths,  the  em- 
ployment of  mild  astringents,  such  as  the  lead  lotion,  or  of  weak 
solutions  of  nitrate  of  silver. 

From  these  eruptive  diseases  of  the  external  organs  we  pass 
now  to  the  study  of  some  other  aflections,  not  so  superficial  in 
their  character,  though  still  seated  exclusively  in  the  integument, 
and  in  the  subjacent  cellular  tissue.  The  correct  classification  of 
these  diseases  is  very  difficult,  for  while  some  are  undoubtedly  of 
syphilitic  character,  others  belong  to  the  same  class  with  lupus, 
and  are  rpiite  independent  of  venereal  taint,  and  of  these  some 
pass  by  gradations  difficult  to  seize  into  the  same  class  with  un- 
doubted epithelial  cancer. 

I  do  not  pretend  to  say  anything  concerning  the  more  usual 
varieties  of  syphilitic  disease  of  the  external  organs.  In  truth, 
my  familiarit3'  with  them  is  but  small.  I  have,  however,  occa- 
sionally met  with  what  would  seem  to  have  been  forms  oitertianj 

1  Vol.  XV,  p.  527. 
34 


530  LUPUS    OF    THE    VULVA. 

syphilis,  but  which  had  been  of  such  long  standing,  and  had  proved 
so  rebellious  to  treatment,  that  questions  had  been  raised  as  to 
whether  they  were  not  really  of  a  malignant  character. 

Such  a  case  was  that  of  a  patient  aged  forty-five,  who  was  ad- 
mitted under  my  care  with  ulceration  of  the  external  parts,  of  a 
year's  duration,  which  appeared  to  have  caused  no  other  consider- 
able inconvenience  than  occasional  difficulty  in  retaining  her  urine. 
On  the  inner  surface  of  her  left  labium,  and  extending  on  to  the 
nympha,  was  a  sore  of  a  semicircular  form,  sliglitly  irregular  in 
its  outline,  its  edges  somewhat  indolent,  its  surface  covered  by 
tolerably  healthy  granulations.  The  concavity  of  the  sore  was 
directed  upwards,  its  convex  edge  downwards,  beginning  by  a 
narrow  edge  about  a  quarter  of  an  inch  below  the  clitoris,  and 
extending  down  to  within  about  three-quarters  of  an  inch  of  the 
lower  part  of  the  left  wall  of  the  vagina.  The  cicatrix  of  a  similar 
sore  occupied  the  inner  surface  of  the  right  nympha,  and  the  right 
side  of  the  entrance  of  the  vagina,  and  a  small  portion  of  its  lower 
edge  was  still  unhealed.  The  orifice  of  the  urethra  was  red  and  ul- 
cerated, but  it  was  not  unnaturally  open.  The  uterus  was  healthy, 
and  there  was  no  enlargement  of  the  glands  in  the  groins. 

In  this  patient  there  were  no  other  venereal  symptoms,  though 
she  confessed  to  having  had  sores  accompanied  by  buboes,  and  by 
sore  throat,  fourteen  years  previousl3\  Recovery,  and  complete 
cicatrization  of  the  sores  took  place  in  three  months,  under  the 
continued  employment  of  the  iodide  of  potass,  with  the  black 
wash  externally,  and  the  occasional  application  of  nitrate  of  sil- 
ver. Other  doubtful  cases  which  have  come  under  my  notice 
have  neither  presented  any  evidence  of  syphilis,  nor  has  it  been 
possible  to  obtain  from  the  patient's  statenients  any  proof  of  its 
previous  existence. 

The  danger  in  such  cases  is  scarcely  of  taking  them  for  scirrhus, 
but  rather  of  confoundinir  them  with  some  forms  of  epithelial  car- 
cinoma. The  stony  hardness  of  a  scirrhous  labium  or  nympha 
has  in  it  something  very  characteristic,  and  the  sore  which  forms 
on  the  mucous  surface  at  that  early  stage  when  alone  mistake  is 
possible,  is  a  mere  superficial  abrasion  of  ephithelium,  not  a  dis- 
tinct ulcer  with  raised  edges.  Genuine  epithelial  carcinoma, 
beginning  on  the  external  parts,  is  less  apt  to  extend  up  the  va- 
ginal canal,  and  does  not  show  the  same  exclusive  preference  for 
the  mucous  surface  of  the  labium;  while,  when  ulcerated,  its 
hardness  usually  extends  deeper,  and  its  surface  presents  a  more 
coarsely  granular  appearance.  From  rodent  ulcer,  or  lupus,  the 
diagnosis  is  more  difficult.  In  that,  however,  the  base  of  the 
ulcer  is  usually  more  indurated,  and  an  indurated  state  of  the  in- 
tegument extends  beyond  the  limits  of  the  ulcer,  producing  in 
vei'y  many  instances  a  marked  contraction  of  the  orifice  of  the 
vulva;  while,  further,  this  disease  is  seldom  limited  to  the  inner 
surface  of  the  labia,  but  in  general  affects  their  posterior  part,  the 
posterior  vaginal  wall  for  a  short  distance,  and  also,  in  many  in- 
stances, the  vestibulum ;  a  greater  extent  of  surface  than  syphilitic 


LUPUS    OF    THE    VULVA. 


531 


disease  commonly  involves,  while  lastly,  in  a  large  number  of 
cases,  there  is  associated  with  the  ulceration  a  very  remarkable 
disposition  to  hypertrophy  of  the  labia  and  nymphse. 

Tiie  last  peculiarity  led  M.  Iluguier,'  who  was  the  first  person 
to  give  a  minute  description  of  this  disease,  to  propose  for  one  of 
its  varieties  the  name  of  hqnis  Itypertrophicus^  designating  its  other 
forms  lupus  serpiginosus,  and  lupus  perforans.  In  most  instances, 
however,  the  characters  are  so  blended  as  to  render  it  doubtful 
whether  there  is  any  special  advantage  in  these  subdivisions.  The 
affection  may  be  briefl}-  described  as  a  form  of  ulceration,  attended 
by  little  pain,  which  creeps  all  round  the  vulva,  healing  at  one  part 
while  it  advances  at  another,  indolent  in  its  progress  towards 
healing,  but  also  extending  slowly;  having  irregular,  usually 
rather  overhanging  edges,  the  tissue  of  which,  and  of  the  parts 
immediately  around,  is  hard  and  cartilaginous.  It  is,  moreover, 
attended  by  a  disposition  to  hypertrophy  of  the  parts  not  destroyed 
by  ulceration,  as  for  instance,  of  the  labia  and  nymph{ie,  and  by 
the  formation  of  condylomatous  groAvths  about  the  entrance  of 
the  vagina,  and  the  orifice  of  the  anus,  which  growths  themselves 
also  become  ulcerated.  It  is  a  farther  characteristic  of  this  affec- 
tion, that  the  ulcerations  in  healing  tend  to  produce  great  con- 
traction of  the  orifice  of  the  vulva,  by  the  formation  of  a  firm 
cicatrix-like  tissue,  Avhich  also  usually  occupies  a  greater  extent 
of  surface  than  the  ulceration  had  done  which  it  succeeds. 

M.  Huguier's  essay  contains  an  account  of  nine  cases  of  this 
disease,  and  five  have  come  under  my  own  observation,  making  a 
total  of  fourteen  cases,  all  of  which  occurred  in  women  who  were 
either  married,  or  were  known  to  have  indulged  in  sexual  inter- 
course, with  the  exception  of  one  of  M.  Huguier's  patients,  con- 
cerning whom  no  mention  is  made  on  this  point.  Onl}-  two  of 
M.  Huguier's  patients,  and  only  one  of  mine,  had  had  children  ;  a 
peculiarity  which  seems  scarcely  accounted  for  by  the  impediment 
which,  when  the  disease  has  reached  an  advanced  stage,  it  may 
present  to  sexual  intercourse : 

The  influence  of  age  in  the  production  of  this  disease  is  shown 
in  the  following  table: 


Patients  came 

under 

Disease  said  to 

Patients  came  under 

Difea<!e  said  to 

notice  at  age 

of 

have  begnn. 

notice  at 

age 

of 

hare  begun. 

Years. 

Years.       Months. 

Years 

Years. 

Months. 

20     . 

.     18              6 

32 

.      30 

4 

21     . 

.     20             6 

32 

.     29 

6 

22    . 

.     20            6 

32 

.     31 

4 

24    . 

.     22            0 

33 

.     25 

0 

26    . 

.     21             0 

38 

.     28 

0 

26    . 

.     25            0 

47 

.     46 

0 

30    . 

.     29            0 

52 

.     45 

0 

1  Seft  his  MStnoir  sur  V Esthiomine  de  la  Region  vulvo-anale,  in  Mhn.  de  V  Acad,  de 
Mederine,  1849,  vol.  xiv,  p.  507.  The  engravings  of  the  disease  are  remarkably 
characteristic  of  its  peculiar  features. 


532 


LUPUS    OF    THE    VULVA. 


Or,  in  other  words,  tlie  disease  began : 


Under      20  years, 

in 

1  case 

Between  20  and  25, 

u 

4     " 

"         25    "    30, 

u 

5     " 

"         30    "    35, 

(1 

2     " 

At            45 

1     " 

"             56 

1     " 

14     " 


The  duration  of  the  disease,  inchiding  the  time  during  which 
the  patients  remained  under  observatiou,  is  shown  in  the  follow- 
ing table: 


Rpsultfl. 


Number. 

Duration. 

'c 

ured. 

Relieved. 

Not  Rulievea. 

Diec 

1 

under 

1  year. 

1 

3 

(( 

18  months, 

2 

1 

3 

11 

2  years, 

2 

11 

1 

II 

3      " 

1 

1 

u 

4      " 

1 

4 

between 

8  and    9, 

3 

1 

1 

u 

10    "    11, 

1 

14  4  6  13 

It  is  quite  evident  that  between  this  affection,  which  runs  a 
course  so  uniformly  slow,  which  admits  of  cnre  after  the  lapse  of 
more  than  three  years,  and  of  great  relief  even  after  eight  years, 
and  any  kind  of  malignant  disease,  there  must  be  an  essential  dif- 
ference. Moreover,  when  it  runs  a  fatal  course,  it  does  not  destroy 
life  as  cancer  does,  either  by  attacking  some  distant  organ,  or  by 
involving,  as  it  extends,  all  the  tissues  in  one  common  morbid 
change,  but  death  takes  place  from  peritonitis  consequent  on  the 
formation  of  fistulous  communications  between  the  vagina  and 
rectum,  and  the  contraction  of  the  bowel  whose  walls  have  become 
implicated  in  the  disease.  The  microscope,  too,  supports  the  dis- 
tinctions which  observation  of  the  general  features  of  the  disease 
suggests.^  ' 

With  reference  to  the  distinction  between  these  ulcerations  and 
such  as  are  really  of  syphilitic  origin,  it  deserves  notice  that  in  one 

'  This  patient  died  under  chloroform,  and  from  the  advance  of  the  disease. 

2  The  following  memorandum  was  made  by  my  friend  Mr.  Paget  of  an  exami- 
nation made  by  him,  after  the  death,  under  chloroform,  of  a  young  woman  in 
whom  a  sore  of  this  kind  had  existed  for  eighteen  months  :  "  In  the  material 
scraped  from  the  surface  of  the  upper  ulcer  there  were  so  many  small  epitheliform 
scales,  of  various  shapes,  with  well-marked  nuclei  and  nucleoli,  and  various  gran- 
ular contents,  that  epithelial  cancer  might  have  been  suspected.  But  all  these 
cells  and  their  nuclei  were  small,  there  were  no  laminated  epithelial  corpuscles, 
and  (which  was  most  significant)  when  I  examined  the  substance  of  its  base,  taking 
it  from  beneath,  and  from  immediately  beneath  its  surface,  1  found  nothing  but 
the  natural  tissues  of  the  mucous  membrane  with  infiltrated,  inflammatory,  or  re- 
parative materials On  the  whole,  the  result  of  the  microscopic 

examination  was  to  show  certainly  that  the  characters  of  these  ulcers  are  like  those 
of  common  ulcers,  having  no  new-formed  structures  of  peculiar  or  specific  form. 
If  the  materials  taken  from  the  surface  of  the  ulcer  had  been  examined  during  life, 
they  would  probably  have  led  to  a  diagnosis  of  epithelial  cancer.  They  were,  how- 
ever, I  imagine,  diseased  epithelial  cells  from  adjacent  parts  of  the  mucous  mem- 
brane, or  perhaps  from  the  healing  part  of  the  surface  of  the  ulcer." 


LUPUS    OF    THE    VULVA.  533 

case  only  of  M.  Iliiguier's  did  tliis  disease  appear  to  be  grafted  on 
syphilitic  mischief;  while  in  the  other  thirteen  cases,  though  one 
of  the  patients  was  a  prostitute,  and  some  of  the  others  had  un- 
doubtedly exposed  themselves  to  the  risks  of  contagion,  not  one 
presented  the  slightest  symptom  of  any  venereal  afiection. 

The  general  character  and  progress  of  the  disease  will,  perhaps, 
be  best  illustrated  by  the  liistory  of  the  case  of  a  Avoman  aged 
thirty,  who  was  admitted  under  my  care  into  St.  Bartholomew's 
IIos[)ital  in  June,  1850.  She  had  then  been  married  four  years, 
had  given  birth  to  one  child  at  the  full  period,  and  had  likewise 
miscarried  from  fright  at  the  fifth  month,  a  year  before  she  came 
under  my  notice.  She  always  had  good  health,  though  her  men- 
struation was  irregular,  until  after  her  labor,  which  was  perfectly 
natural.  She  got  about,  however,  too  soon  after  her  confinement, 
and  to  this  indiscretion  she  attributed  a  leucorrhoeal  discharge, 
frequently  streaked  with  blood,  from  which  she  had  sufiisred  ever 
since.  This  discharge  had  become  more  profuse  since  her  mis- 
carriage, but,  with  the  exception  of  slight  pain  in  the  back,  she 
had  not  experienced  any  other  inconvenience  until  two  months 
previoush^  Since  that  time,  however,  she  had  had  a  good  deal 
of  pain,  both  in  micturition,  and  in  sexual  intercourse,  and  the 
discharge  had  become  yellow,  thick,  ofiensive,  and  escaped  in 
gushes.  The  patient  said  that  she  had  lost  flesh,  but  she  did  not 
appear  either  emaciated  or  seriously  out  of  health. 

The  labia  and  nymphfe  were  much  swollen,  but  not  diseased ; 
a  very  abundant,  dirty  puriform  discharge  escaped  on  separating 
them.  A  red,  granular,  bleeding  ulceration,  with  a  hard  surface, 
slightly  painful  to  the  touch,  and  bleeding  readily,  surrounded  the 
urethra,  while  the  finger  introduced  into  the  vagina  discovered  a 
continuation  of  a  similar  condition  extending  upwards  for  about 
an  inch  in  breadth,  by  an  inch  and  a  half  in  length.  That  part  of 
the  disease,  however,  wliich  extended  within  the  vagina  was  not 
entirely  in  a  state  of  ulceration,  but  a  thickening  and  infiltration 
of  the  tissues  reached  for  some  distance  on  either  side,  and  the 
actual  ulceration  was  of  very  limited  extent.  On  the  posterior 
vaginal  wall,  a  little  distance  from  the  orifice  of  the  canal  was  a 
smiall,  hard  tubercle,  the  size  of  the  top  of  the  little  finger,  covered 
by  unchanged  mucous  membrane. 

Six  months  later,  the  external  parts  were  more  tumid,  and  both 
they  and  the  inside  of  the  thighs  were  excoriated  by  the  profuse 
discharge.  The  tubercle  on  the  posterior  vaginal  wall  remained 
unaltered,  but  a  strip  of  ulceration  was  creeping  up  on  either  side. 
Five  months  later,  or  in  the  middle  of  May,  1851,  the  patient  be- 
came again  pregnant,  and  on  February  19,  1852,  she  was  delivered 
of  a  live  female  child,  alter  a  labor  of  little  more  than  five  hours' 
duration.  The  tubercle  at  the  posterior  wall  of  the  vagina  had 
somewhat  increased  during  her  pregnancy,  and  the  perineum  felt 
hard  and  brawny.  It  gave  way  during  the  passage  of  the  head, 
but,  nevertheless,  the  patient  passed  through  the  puerperal  state 


534  LUPUS    OF    THE    VULVA. 

without  any  bad  symptom,  and  on  the  18th  of  March  was  again 
received  into  the  hospitaL 

The  hihia  were  then  greatly  swollen,  but  neither  from  anasarca, 
nor  from  inflammation.  Their  surface  was  pale  and  much  wrinkled, 
like  the  hand  when  long  soaked  in  water,  while  the  whole  of  the 
integument  felt  thickened  like  that  of  a  part  aftected  with  ele- 
phantiasis. The  nymph?e  were  also  greatly  enlarged,  and  pro- 
jected between  the  labia,  but  otherwise  their  tissue  did  not  appear 
to  be  much  altered,  except  on  their  inner  ulcerated  surface.  On 
separating  the  nymphse  an  irregular  ulceration  was  seen  surround- 
ing the  urethra,  which  it  seemed  to  have  partially  detached  from 
its  superior  connections,  and  passing  up  under  the  symphysis 
pubis.  The  clitoris  appeared  to  have  been  destroyed  by  the  ulce- 
ration, which  extended  up  quite  to  the  superior  commissure  of  the 
labia,  whence  it  passed  on  to  the  inner  surface  of  the  nymphse, 
while  pale  rose-colored  warty  granulations,  exactly  like  those  of 
the  ulceration,  surrounded  the  edges  of  the  urethra,  and  formed  a 
prominence  about  it  almost  of  the  size  of  a  hazel-nut.  The  edges 
of  the  lacerated  perineum  were  cicatrized  to  the  extent  of  about  a 
third  of  an  inch,  but  the  rest  of  the  ununited  margins  of  the  labia, 
and  the  walls  of  the  vulva  and  vagina  as  far  as  could  be  seen,  were 
of  harder  texture  than  natural,  semicartilaginous,  of  a  pale  rose-red 
color,  destitute  of  epithelium,  smooth,  and  not  granular-looking, 
but  just  like  a  section  of  a  scirrhous  mass,  and  pouring  forth  a 
copious  sero-purulent  secretion.  A  granulating  ulceration  ex- 
tended for  between  half  an  inch  and  an  inch  along  both  walls  of 
the  vagina,  that  on  its  posterior  wall  ceasing  at  the  base  of  the 
tubercle  already  mentioned  as  situated  there. 

The  removal  of  the  nymphre  was  followed  by  great  general 
amendment,  and  by  partial  cicatrization  of  the  sore  that  sur- 
rounded the  urethra.  The  granular  outgrowth  immediately  at 
its  orifice  had  by  the  end  of  May  lost  nearly  the  whole  of  its  pre- 
ternatural redness,  and  was  covered,  as  were  the  condylomatous 
growths,  with  pale  mucous  membrane.  The  inner  surface  of 
each  labium,  which  looked  before  like  sections  of  carcinomatous 
growths,  was  covered  by  healthy  mucous  membrane.  On  the 
8th  of  July,  1852,  just  two  years  from  tlie  patient's  first  coming 
under  my  notice,  there  no  longer  existed  anj'  positive  ulceration, 
though  in  other  respects  matters  continued  much  as  before,  except 
that  a  vividly  red,  though  but  slightly  sensitive  excrescence,  as 
big  as  the  tip  of  the  little  finger,  now  sprouted  from  tlio  wall  of 
the  urethra  and  quite  filled  up  its  canal,  while  the  papillae  which 
beset  its  margin  continued  as  before. 

From  this  time  I  never  saw  the  patient  again  ;  but  this  un- 
finished history  displays  the  peculiarities  of  the  disease,  its  slow 
progress,  and  its  partial  amendment.  I  wish  it  illustrated  more 
favorably  the  results  of  treatment,  though  indeed  the  patient  left 
the  hospital  better  in  many  respects  than  when  she  entered  it,  and 
this  in  spite  of  its  never  having  been  possible  to  induce  her  to 
remain  there  for  more  than  three  months  at  a  time.   To  a  certain 


CANCER    OF    THE    VULVA.  535 

extent  good  diet,  rest,  cleanliness,  the  use  of  the  hip-bath,  and 
simple  unirritating  lotions  improve  the  state  of"  the  ulceration ; 
and  I  have  sometimes  flattered  myself  that  cicatrization  would 
speedily  take  place.  In  a  few  weeks,  however,  the  limit  of  this 
improvement  has  usually  been  attained,  and  the  patient  has  passed 
from  under  my  care  benefited  indeed,  but  by  no  means  cured.  In 
the  only  instance  ftn  which  complete  recovery  took  place,  the 
patient  was  kept  steadily  on  a  course  of  mild  mercurial  medicine 
with  small  doses  of  the  iodide  of  potassium  for  nearly  two  months. 
In  this  instance,  however,  the  ulceration  did  not  date  from  longer 
than  seven  months  previously,  and  the  amount  of  thickening  and 
hypertrophy  of  the  nymphfe  was  inconsiderable. 

In  other  cases  I  have  emploj^ed  preparations  of  mercury,  iodine, 
and  arsenic,  without  having  been  able  to  attribute  to  any  one  of 
them  a  special  influence  over  the  disease,  and  the  experience  of 
M.  Huguier  does  not  in  these  respect  differ  from  my  own.  One 
point  to  which  he  refers  is  of  great  moment,  namely,  the  expe- 
diency of  removing  the  nymphfe,  or  any  of  the  adjacent  parts 
which  may  readily  admit  of  extirpation,  provided  the  ulcerations 
upon  them  appear  indisposed  to  heal.  I  should  indeed  be  inclined 
to  advocate  in  every  case  the  removal  both  of  the  ulcerated  nym- 
phfe,  and  also  of  all  those  papillary  or  condylomatous  excrescences 
which  beset  the  orifice  of  the  vulva  as  a  preliminary  step  to  any 
attempt  at  the  cure  of  the  disease.  The  opposing  surfaces  keep 
up  mutual  irritation,  while  the  hardened  tissues  prevent  any  ap- 
plication being  efl'ectually  made  to  the  ulceration  about  the  vesti- 
bule. The  outgrowths,  too,  around  the  vulva  are  apt  to  become 
the  seat  of  ulceration,  and  also  to  increase  by  their  presence  the 
probabilities  of  the  occurrence  of  a  relapse.  I  am  unable  to  say 
to  what  extent  the  use  of  the  stronger  caustics,  such  as  the  acid 
nitrate  of  mercury,  may  be  of  service  in  those  instances  in  which 
the  ulcerations  are  most  indolent,  but  I  am  inclined,  thoufi^h  from 
very  slight  experience  on  the  subject,  to  think  that  whore  its  appli- 
cation is  practicable,  the  influence  of  the  actual  cautery  is  more 
beneficial  in  modifying  the  state  of  the  parts  than  that  of  any  kind 
of  chemical  escharotic. 

3Ialignavt  disease  of  the  external  parts  usually  assumes,  as  might 
be  expected,  the  form  of  epithelial  cancer,  though  a  case  of  scirrlius 
of  the  labium  and  one  of  fungoid  disease  of  the  vulva  have  both 
come  under  my  notice.  E[)itlielial  cancer  generally  commences 
in  the  form  of  a  little  hard  tubercle  on  the  outer  surface,  but  near 
to  the  edge  of  the  labium,  and  without  being  the  seat  of  positive 
pain,  is  yet,  in  most  instances,  a  source  of  annoyance  by  the  smart- 
ing and  itching  which  it  occasions.  It  may  continue  thus  for  an 
uncertain  period — for  several  months,  perhaps  for  longer,  till  at 
length  its  surface  becomes  abraded,  a  serous  discharge  exudes 
from  it,  and  then  completely  losing  its  epithelium,  it  presents  the 
appearance  of  a  circular  sore  seated  on  a  hard,  somewhat  raised 
base.  It  now  spreads  by  ulceration,  the  ulcer  always  retaining 
somewhat  of  a  circular  form,  while  with  its  extension  the  indurated 


536  CANCER    OF    THE    VULVA. 

base  also  reaches  further  and  further  beyond  tlie  limits  of  the 
ulceration.  It  constantly  displays  an  indolent  character,  its  edges 
being  hard,  and  its  surface  depressed  a  little  below  the  level  of 
the  surrounding  integument.  The  granulations  so  distinctive  of 
the  ulceration  of  epithelial  cancer  are  frequently  kept  in  check  by 
the  constant  attrition  of  the  opposing  surfaces  of  the  labia,  for  it 
is  worth  notice  that,  though  the  disease  usually  commences  at  the 
edge  of  the  labium,  the  ulceration  generally  advances  inwards 
towards  its  mucous  surface,  and  comparatively  seldom  spreads 
outwards  on  the  integument.  From  the  inner  surface  of  the 
labium,  it  next  involves  the  nympha,  the  pni^putium  clitoridis, 
and  the  clitoris  itself,  which  parts,  before  they  are  attacked  by 
actual  ulceration,  generally  become  red,  abraded,  and  finely  gran- 
ular on  their  surface. 

For  some  time  even  after  the  ulceration  has  taken  place,  the 
inguinal  glands  continue  healthy  and  are  not  enlarged,  and  the 
general  substance  of  the  labium  is  not  aflected.  Presently,  how- 
ever, the  ulceration  extends  in  depth  ;  as  it  does  so,  it  grows  more 
irregular,  and  the  granulations  that  bespt  its  surface  become  larger, 
wdiile  the  whole  labium  now  looks  red  and  swollen,  feels  hard,  and 
slightly  irregular,  and  is  very  teuder  to  the  touch. 

There  is  little  ditficultv  in  tilling  \\\)  the  picture,  with  the  few  dark 
touches  needed  to  complete  it.  The  disease  sometimes  destroys 
the  hibium,  and  then  extends  upon  the  integument  of  the  thigh,  as 
a  deep,  excavated,  ragged  ulcer,  which  yet  does  not  in  general  dis- 
charge much,  nor  invariably  occasion  severe  pain.  At  other  times 
a  gland  swells,  increases  rajjidly  in  size,  the  skin  over  it  then  dies, 
and  a  large  cancerous  ulcer  is  left  behind,  while  as  the  disease  ad- 
vances, the  patient  loses  health  and  flesh,  and  fades  away,  not 
destroyed  by  hemorrhage,  as  in  uterine  cancer,  nor  by  any  means 
constantly  worn  out  by  pain,  for  that  is  usually  tolerably  amenable 
to  opiate  remedies. 

I  should  perhaps  mention  that  I  have  seen  one  instance  of  the 
commencement  of  epithelial  carcinoma,  not  on  the  cutaneous  sur- 
face of  the  labium,  but  on  the  outer  surface  of  the  left  nympha  in 
a  young  married  woman  thirty-one  years  old.  The  disease  had 
the  form  of  a  deep  hole,  with  ragged  edges,  apparently'  about  large 
enough  to  contain  a  nut,  but  the  edges  were  so  close  together  that 
it  was  impossible  to  see  to  the  bottom  of  it,  while  any  attempt  to 
separate  them  in  order  to  ol)tain  a  good  view  gave  so  much  pain 
that  it  was  forced  to  be  abandoned.  Its  edges  and  surface  were 
made  up  of  small  red,  semi-transparent  granulations  of  the  size  of 
a  pin's  head,  and  remarkably  characteristic  of  epithelial  cancer. 

The  commencement  of  the  disease  was  referred  to  a  fall  against 
the  edge  of  a  chair  five  months  before,  when  the  patient  hurt  the 
external  parts  very  much,  and  sufl'ered  from  profuse  hemorrhage 
in  consequence.  She  Avould  not  submit  to  an  operation  then,  but 
returned  to  the  hospital  a  year  afterwards,  when  all  interference 
was  out  of  the  question,  for  the  ulceration  had  destroyed  the 
labium,  and  extended  to  the  thigh.     The  poor  woman  had  fol- 


CANCER    OF    THE    VULVA.  537 

lowed  her  occupation  as  a  weavcress  almost  to  the  time  of"  her 
admission,  had  suffered  much,  had  fared  ill,  and  had  taken  to 
opium-eating  for  relief.  She  was  transferred  to  the  workhouse, 
but  1  do  not  know  when  she  died.^ 

Our  data  are  hardly  sufficient  to  determine  satisfactorily  the 
duration  of  this  disease.  I  believe,  however,  that  the  tubercle 
which  precedes  the  development  of  the  carcinomatous  sore  may 
exist  for  a  long  period,  even  for  several  years,  though  1  do  not 
imagine  this  usually  to  be  the  case ;  but  that  when  the  process  of 
ulceration  has  commenced  it  runs  its  course  to  a  fatal  issue  within 
two  3'ears. 

In  the  treatment  of  epithelial  carcinoma  the  one  great  question 
to  decide  concerns  the  possibility  of  its  removal.  If  let  alone,  at 
any  rate  after  ulceration  has  commenced,  its  progress  is  invaria- 
bly to  a  fatal  issue  ;  and  any  of  the  local  applications  which  may 
be  tried  in  ulcerations  of  a  doubtful  character  on  other  parts  can 
never  be  efficiently  employed  in  diseases  of  the  external  sexual 
organs  of  women.  I  have  not  experience  enough  to  say  in  what 
proportion  of  cases  the  disease  recurs,  or  how  long  a  period  of 
immunity  may  be  hoped  tor  after  its  extirpation.  Of  this,  how- 
ever, I  am  sure,  that  present  comfort  is  promoted,  that  life  is  de- 
cidedly prolonged,  and  that  a  chance,  if  but  a  slender  chance,  at 
any  rate  the  only  one,  is  thereby  afforded  the  patient  of  a  perma- 
nent cure.  The  surgery  of  the  operation  lies  beyond  my  province ; 
the  only  suggestion  that  I  would  venture  to  give  concerning  it  is, 
that  care  should  be  taken  to  remove  enough,  and  that  the  opera- 
tor should  not,  through  fear  of  making  too  large  a  wound,  carry 
his  incisions  too  near  to  diseased  tissues. 

1  I  have  also  seen  one  instance,  in  a  woman  aged  thirty-four,  of  the  simultane- 
ous occurrence  of  malignant  ulceration  of  the  interior  of  the  labia  and  nymphae, 
and  of  epithelial  carcinoma  of  the  skin  over  the  pubes.  Death  took  place  in 
twenty  months.  There  was  infiltration  of  cancerous  matter  into  the  body  of  the 
uterus,  but  its  cervix  was  healthy,  and  no  secondary  deposits  existed  in  any  other 
organ. 


INDEX. 


Abdomen,  encysted  dropsy  of,  434 
floating:  tumors  of  (note),  434 
Abortion,  share  of,  in  production  of  uterine 
ailments,  113 
cause  of  inflammation  of  uterine  appen- 
dajres.  337 
Amenorrhoea,  from  defective  formation,  37 
mechanical  causes,  38 
in  opposite  states  of  the  system,  41 
suppression  of  menses,  49 
vicarious  hemorrrhnges  in,  47 
treatment  of,  45,  51 
Anteflexion  of  uterus,  a  natural  condition,  167 
comparative  frequency  of  it  and  of  re- 
troflexion, lfi6 
Anteversion  of  uterus,  lfi3 
Ascent    of    the    uterus,    its   causes    and  im- 
port, 202 
Ascites,  diagnosis  of,  from  ovarian  dropsy, 429 


Bladder,  distended,   diagnosis  of,  from  ova- 
rian dropsy,  433 
prolapsus  of,  135 

its  characters,  and  mode  of  produc- 
tion, 136 
effect  on  the  uterus  and  kidneys,  137 
symptoms,  143 
treatment,  151 
affections,    often  secondary  to    those   of 

uterus,  484 
inflammation  of,  484 
chronic,  485 

relation  of,  to  disease  of  kidneys,  487 
treatment,  489 
fungous  tumors  of,  495 
malignant  disease  of,  496 
Blood,   alterations  of,  as  cause  of  amenor- 
rhoea. 42 
of  menorrhagia,  53 
Boils,  affecting  the  labia,  519 


Cancer  of  the  bladder,  496 

of  the  vagina,  514 

of  the  vulva,  635 

of  uterus,  276 

definition  of  it.  278 

scirrhous  cancer,  278 

medullary  cancer,  279 
ulceration  of,  2H0 
attempts  at  healing,  281 
general  changes  in  uterus,  283 
on  its  exterior,  283 

affection  of  the  bladder  in,  285 

of  body  of  uterus,  286 


Cancer,  cancerous  polypi,  287 
alveolar,  288 
epithelial,  288 

ulceration  of,  291 
secondary  deposits  in,  293 
relation  of,  to  fibrous  tumors,  224 
diagnosisof,  from  fibrous  tumors,  237,314 

simple  induration,  312 
frequency  of.  294 

influence  of  age  on,  296 

uterine  functions,  296 
influence  of  pregnancy  and  labor, 298 
hereditary  predisposition,  300 
symptoms  of,  300 
pain,  301 

occasional  absence  of,  303 
hemorrhage,  303 
discharge,  306 
cancerous  cachexia,  307 
sometimes  latent,  310 
acute  cancer,  310 
complicating  labor,  311 
duration  of,  315 
treatment,  316 

of  the  hemorrhage,  317 
pain,  319 
discharges,  322 
cachexia.  323 
labor  with,  324 
extirpation  of  uterus,  326 
excision  of  cervix  uteri,  328 

and  ligature  com]iared,  332 
employment  of  cold,  333 

caustics  and  of  actual  caute- 
ry, 334,  335 
Carbonic  acid  gns,  as  local  anassthetic,  320 
Cauliflower  excrescence,  2^8 
Caustics,  mode  of  applying  to  os  uteri,  123 

evils  of  their  too  frequent  use,  111 
Cellulitis,  336 

Cervix  uteri,  comparative  physiological  im- 
portance of  it  and  of  body  of  uterus,  100 
alleged  importance  of  its  iiiliiieiits,  117 
sometimes  chief  source  of  discharge,  125 
hypertrophy  of,  88 

in  cases  of  prolapsus,  131,  134,  136 
excision  on  account  of,  89 
cyst-formation  in,  124.  209 
removal  of,  in  cases  of  cancer.  328 
Chloroform,  vapor  of,  as  local  anoesthetic,  320 
Chlorosis,  43 

Clitoris,   its  excision   in   cases  of  masturba- 
tion, 527 
Coccyx,  pain  at,  or  ooccypodynia,  526 
Corroding  ulcer  of  uterus,  2'.'2 
Cowper's  gland,  inflammation  of,  517 


640 


INDEX. 


Cretins,  ptiberty  late  in,  41 
Cysts  of  cervix  uteri,  124,  209 
diagnosis  of.  2 II 
treatment  of,  213 
on  exterior  of  uterus  (note),  390 
of  ovaries,  varieties  of,  393 

their  comparative  frequency, 406 
Wolffian  bodies,  394 
vagina,  510 


Diabetes,  a  cause  of  pruritus  of  vulva,  20 
Diagnosis,  errors  in,  illustrated,  19 
Digitalis,  use  of,  in  menorrhagia,  fi2 
Diseases  of  women,  study  of,  iin])ortiint,  18 
errors  committed  in,  18 
disturbance  of  function  in,  20 
sensibility  in,  22 
Dysmenorrbcea,  68 
neuralgic,  69 

its  treatment,  74 
congestive,  70 

membrane  expelled  in,  71 
its   relation    to    gout   and    rheuma- 
tism, 72 
its  treatment,  77 
treatment  of  rheumatic  cases,  79 
mechanical,  73 

its  treatment,  80 


Eoraseur,    for   amputation  of  cervix    uteri, 

dangers  of,  00,  333 
Eczema  of  vulva,  519 
Emmenagogues,  remarks  on,  47 
Enlargement  of  uterus,  from  defective  invo- 
lution (see  Hypertrophy),  85 
Enucleation  of  fibrous  tumors,  250 
Examination    in    diseases   of    women,    rules 
For.  23 
of  abdomen,  25 
vaginal,  26 
by  rectum,  27 
with  sound.  27 
with  speculum,  31 
Excision  of  portion  of  wall  of  ovarian  cyst,  458 
External  peritonitis,  349 
Extirpation  of  uterus,  when  procident,  158 
when  inverted,  196,  200 

by    ligature     and    knife    com- 
pared, 197,  201 
in  cases  of  cancer,  326 


Fallopian  tube,  its  unnatural  patency  (note), 
86 
discharge  of  ovarian  cyst  through  it,  410 
Fat-cysts  of  ovary,  402 
Fatty  tumors  of  uterus,  273 
Fibrinous  polypus  (see  Polypus),  213 
Fibro-cystic  tumors  of  uterus  (note),  220 

polypi  (note),  215 
Fibroid  (recurrent)  tumors  of  uterus,  268 
Fibrous  polj-pus  (see  Polypus),  262 

tumors  of  uterus,  general  characters  of, 
216 
microscopic  structure,  216 
relations  of,  to  uterus,  217 
size  and  number,  219 
containing  large  cysts  (note),  220 
spontaneous  cure  of,  220 
softening  of,  221 


Fibrous  tumors  of  uterus,  calcification  of,  222 
relation  of,  to  malignant  disease,  223 
influence  of  age  on,  225 

marriage  on,  226 
symptoms  of,  226 
influence  of,  on  fecundity,  228 
state  of  uterus  in,  230 
diagnosis  of,  232 

from  ovarian  tumor,  234,  427 
abortion,  2'U 
flexions  of  uterus,  236 
cancer  of  uterus,  237,  314 
associated  with  intense  pain,  237 
from  pregnancy,  239 
prognosis  of,  242 

complicating  pregnancy,  243 
treatment,  244 

use  of  iodine,  247 

the  Kreuznach  waters,  247 
extirpation  of,  249 
of  labor  complicated  with,  256 
tumors  of  vagina,  612 
Fistula,  intestino-vesical,  494 

vesico-vaginal,  492 

Flexions  of  uterus.  165 

how  produced,  167 

comparative  frequency  of  ante-  and  retro- 
flexion, 166 
anatomical  results  of,  169 
congenital,  169 
symptoms  of,    170,  175 
their  importance  overrated,  171 
symjttoms  of,  accounted  for,  174 
diagnosis  of,  178 
treatment,  180 

employment  of  mechanical  means, 
181 
Follicular  inflammation  of  vulva,  529 
Formula3,  aperient,  chalybeate,  46 
astringent,  60,  61 
anti[ihlogistic,  sedative,  60 
mucilaginous,  324 
stimulant,  75 
anodyne  liniment,  121 
for  cases  of  cystitis,  490 
sedative  lotions,  520,  522 


Gangrenous  inflammation  of  vulva,  517 
Gonorrhoea,  its  diagnosis  not  always  possible, 
510 
a  cause  of  acute  metritis,  91 
Granular  vaginitis,  510 


IIoDmatoeele,  uterine,  its  nature,  359 

sj'inptoms  and  course,  363 

cases  illustrative  of,  365 

diagnosis,  371 

prognosis,  373 

treatment,  375 

indications  for  puncture,  377 
Hair  in  ovarian  cysts,  402 
Hymen,  imperforate,  38 
Hypertrojihy  of  uterus,  from  defective  invo- 
lution, 85 

from  sterile  marriage,  87 

of  cervix  only,  88 

parti.-il,  206 
Hysteria,  peritonitis  simulated  by,  20 


Idiots,  puberty  late  in,  41 


INDEX. 


541 


Inflammation   of    uterus,    difficulties    in    its 
study,  90 
acute,  its  causes  and  symptoms.  90 

treatment,  92 
chronic,  94 

treatment,  119 
uterine  appendages  (see  Uterus,  appen- 
dages of),  ySfi 
Iodine,  injection  of,  into  ovarian  cysts,  459 
itsdnngers  and  results,  4(>2 
points  on  which  information  needed,  466 
Intra-uterine  injections,  in  monorrhagia,  66 
Inversion  of  uterus,  188 
its  causes,  188 

symptoms  at  time  of  its  occurrence, 

189 
results,  191 
spontiineous  replacement  of,  192 
diagnosis  of,  when  recent,  193 

chronic,  199 
treatment—  attempts  at  replacement,  194 

extirpation  of  uterus,  196,  200 
from  polypus,  201 
Involution  of  uterus  ;  results  of  its  interrup- 
tion, 84 
Irritable  uterus,  72 

Kidneys,  atrophy  of,  from  prolapse  of  blad- 
der, 137 
in  cancer  of  uterus,  302 
disease  of.  producing  symptoms  of  cysti- 
tis, 487 
Kreuznnch,  waters  of,  in  cases  of  fibrous  tu- 
mor, 247 

Labia,  inflammation  of,  517 

boils  on,  519 
Labor,  share  of,  in  production  of  uterine  ail- 
ments, 113 
cause  of  inflammation  of  uterine  appen- 
dages?, 337 
complicated  with  polypus,  267 
fibrous  tuuior,  244,  258 
cancer,  31 1,  324 
induction  of,  prematurely,  in  fibrous  tu- 
mor, 258 
Leeches  to  uterus,  how  applied,  78 

caution  with  reference  to  their  use,  93, 
119 
Leucorrhcea,  cervix  uteri  its  alleged   source, 
117 
treatment  of,  121 
cervical,  treatment  of,  125 
vaginal,  microscopic  character  of,  506 
treatment  of,  508 
Lupus  of  vulva,  531 

Malformation   of  sexual  organs,  a  cause  of 

amenorrlxjea,  37 
Masturbation,  removal  of  clitoris  for,  527 
Menorrhiigia,  its  causes  twofold,  52 
con.^itiiutional  causes  of,  63 
from  local  causes,  56 
occiisional  death  from,  63 
its  treataient,  58 

of  cases  requiring  depletion,  60 
use  of  astringents  in,  61 
digitalis  in,  62 
local  measures  in,  64 
intra-uterine  injections  in,  66 


Menorrhagia,  .scraping  uterine  mucous  mem- 
brane in,  67 
Menstruation,  various  causes  of  its  disorders, 
21,  34 

disorders  of,  referred  to  three  classes,  34 

first,  average  djite  of,  35 

tardy,  usually  difficult,  36 

precocious  (note),  63 
Metritis,  acute,  90 

hemorrhagic,  60 


Nabothian  bodies  ;  their  nature,  124 
enlarged,  208 

cyst-formations  from,  209 


Obliquity,  congenital,  of  uterus,  169 
Ovaries,  special  function  of,  20 
defective  development  of,  37 
displacement  of,  389 
hernia  of  (note),  390 
inflammation  of,  378 

in  cases  ol  acute  metritis.  93 
rare  in  an  acute  form,  382 
occasional  occurrence  of  abscess,  383 
most  frequently  chmnic,  385 
symptoms  of  chronic  ovaritis,   385, 

388 
treatment,  387,  390 
simple  cvsts  of,  connected  with  Wolffian 
body,  393 
often  stationary,  407 
from  enlarged  Graafian  vesicles,  395 
from  other  causes,  398 
sometimes  stationary,  407 
disappear,  409 
compound  cysts,  398 

cysto-sarcomatous,  400 
colloid  cysts,  401 
cancerous,  402 
fat-cysts,  402 

frequency  of  different  cysts,  406 
difi"erent "kinds  of,  402 
cysts  of,  discharge  of,  by  various  chan- 
nels. 410 
danger  of  rupture  into  peritoneum, 

413 
inflammation  of,  414 
Ovarian  dropsy,  disorder  of  health  from,  415 
predisposing  causes  of,  417 
exciting  causes  of.  420 
early  symjitoms  of,  421 
advanced  symptoms  of,  423 
diagnosis  of,  233,  373,  420 
prognosis  of.  437 
treatment,  439 

palliative,  440 

tapping  in,  442 
radical,  450 

tight  bandage  after  tapping,  450 
subcutaneous  )iuncture,  452 
puncture  per  vaginani,  452 
maintenance  of  opening,  453 
excision  of  jiortinn  of  wall,  453 
iocline  injections.  459 
extirpation  of  ovary,  468 
Ovariotomy,  4i'))S 

often  impracticable,  470,  474 
two  operations,  46'J 

their  results  compared,  474 
its  mortality  (note),  469,  478 


542 


INDEX. 


Ovariotomy,  its  mortality,  causes  of,  471 

and  of  Caesarean  section  compared, 
472,  478 
reasons  for  formerly  rejecting  the  opera- 
tion, 476 
these  reasons  reconsidered,  478 
indications  for  and  against  it,  stated,  482 


Pelvic  cellulitis,  336 

diagnosis  from  uterine  haematocele,  351, 
372 
Peritoneum,  rupture  of  ovarian  cyst  into,  413 
Peritonitis,  hysterical,  20 

external,  349 
Pessaries,  their  diiferent  kinds,  146 

rules  for  their  introduction,  150 
Plug,  in  cases  of  menorrhagia,  64 

operations  on  uterus,  332 
Polypus  of  uterus.     Mucous  polypus,  207 
Glandular,  208 

symptoms  of,  209 
sources  <»f  hemorrhage  in,  210 
diagnosis  of,  211 
removal  of,  212 
Fibrinous,  213 

its  nature,  symptoms,  and  troatment, 
214 
Fibro-cystic  ;  its  nature  doubtful  (note), 

215 
Fibrous  ;  structure  of,  259 

source  of  hemorrhage  in,  210,  260 
development  of,  262 
inversion  of  womb  by,  201 
symptoms  of,  262 
diagnosis,  263 

and  of  inverted  womb,  199 
management  of  labor  with  it,  267 
removal  by  ligature  or  excision,  263 
Malignant,  288 
Pregnancy,  share  of,  in  production  of  uterine 
ailments,  1 13 
obscured  by  fibrous  tumors,  240 
diagnosis  of,  from  fibrous  tumor,  239 

ovarian  dropsy,  434 
rendered  dangerous  by  fibrous  tumors, 
243 
cancer,  311 
extra-uterine,    diagnosis    from    uterine 
haematocele,  371 
Procidentia  of  uterus,  132 
its  symptoms,   140 
treatment  of,  151 

cautions  in  returning  it,  152 
operations  for  its  cure,  153 
failure  of  all  operations,  155 
danger  of  Huguier's  operation,  157 
extirpation  of  uterus  for,  158 
Prolapsus  uteri,  its  different  degrees,  127 
anatomical  arrangements  which  prevent 

its  occurrence,  128 
its  causes,  129 

mode  of  production  in  the  aged,  130 
alterations  in  the  uterus  itself  from  it, 

131 
complete  prolapse,  or  procidentia,  132 
secondary  to  prolapse  of  vagina,  133 
symptoms  of  its  earlier  stages,  138 

complete  prolapse  (see  Procidentia), 
140 
associated  with  pregnancy,  142 
its  treatment,  143 


Prolapsus  uteri,  mechanical  support, when  to 
be  used  (see   Pessaries  and  Supports), 
145 
of  vagina,  133 

a   cause  of  hypertrophy   of  cervix 

uteri,  134,  136 
partial,  of  anterior  or  posterior  wall 

(see  Bladder,  prolapse  of),  135 
symptoms  of,  142 
Pruritus  of  vulva,  621 

attendant  on  diabetes,  19 
Puberty,  precocious  (note),  53 

tardy,  from  various  causes,  36,  40 
Puncture,  subcutaneous,  of  ovarian  cyst  (see 
Tapping),  452 


Rectum,  prolapsus  of,  137 

its  treatment,  143 
Recurrent  fibroid  tumors  of  uterus,  268 
Retroflexion  of  uterus,  comparative  frequency 

of  it,  and  of  anteflexion,  166 
Retroversion  of  uterus,  160 

mode  of  its  production,  160 

causes  of,  161 

diagnosis  from  uterine  ha3matocele,  372 
ovarian  tumors,  428 
Rodent  ulcer  of  uterus,  292 
Rupture,  spontaneous,  of  ovarian  cyst,  410 


Scarification  of  uterus  ;  its  uses,  79 

Scirrhus  of  uterus,  278 

Secretions,  from  sexual  organs  ;  their  various 

sources,  22 
Sensibility,  disorders  of,  in  diseases  of  women, 

22 
Sound,  uterine  ;  by  whom  suggested,  27 

Dr.  Simpson's  described,  28 

mode  of  introduction,  28 
Speculum  uteri,  invention  of,  29 

varieties  of,  30 

mode  of  introduction,  31 

its  value  estimated,  33 
Support,  mechanical,  in  prolapsus  uteri,  145 

internal,  146 

external,  149 
Supporter,  the  uterine,  182 

objections  to  its  use,  183 
Sterility,    influence  of  flexions  of  uterus  in 
producing  it,  177 

polypi,  211 

fibrous  tumors,  228 
Syphilis,  tertiary,  of  vulva,  529 

Tapping  in  ovarian  dropsy,  442 

attitude  in,  447 

its  dangers  estimated,  443 

exhaustion  after,  448 

cyst-inflammation  from,  448 

followed  by  tight  bandaging,  450 

subcutaneous,  452 

per  vaginara,  452 

and  maintenance  of  opening,  453 
injection  of  iodine,  459 
Teeth  in  ovarian  cysts,  402 
Trichomonas,  characteristic  of  vaginal  len- 

corrhcea,  506 
Tubercle  of  uterus,  274 

ulcerations  said  to  be  tuberculous,  291 
Tumors,  floating,  of  abdomen  (note),  436 


INDEX. 


543 


Ulcer,  rodent,  of  uterus,  292 
Ulceration  of  os  uteri ;  its  characters,  101 
its  alleged  importance,  102 
importance  doubted,  103 
success  of  local  treatment  explained, 

108 
local  treatment  sometimes  mischiev- 
ous, 109 
objections  to  frequent  use  of  caustics, 

111 
local  treatment,  when  necessary,  123 
Urethra,  congestion  of,  498 
vascular  tumors  of,  500 
chronic  ulceration  of,  503 
Urine,  albumen  in,  from  presence  of  leucor- 

rhoea,  19 
Uterine  sound  (see  Sound),  27 
Uterus,  absence  of,  38 

knowledge  of  its  structure  and  diseases 

formerly  defective,  95 
assumed  constitutional  origin  of  its  dis- 
eases, 97 
its  special  liability  to  disease  accounted 

for,  98 
inflammation  of  its  cavity  and  body,  90 
cancerous,  extirpation  of,  326 
appendages  of,  inflammation  of,  336 
its  causes,  337 
extent  to  which  peritonitis  attends 

it,  341 
tendency  to  suppuration,  341,  345 
post-mortem  appearances,  342 
process  of  cure  of,  343 
nature  and  analogies  of,  344 
its  symptoms,  345 

chronic  course,  347,  351 


Uterus,  appendages  of,  inflammation  of,  di- 
agnosis, 348,  426 
occasionally  independent    of    puer- 
peral causes,  353 
its  treatment,  355 

puncture,  when  indicated,  358 

Vagina,  acute  inflammation  of,  505 
its  treatment,  507 

chronic  inflammation  of,  507 
its  treatment,  508 

cysts  of,  510 

fibrous  tumors  of,  512 

malignant  disease  of,  513 

extension    of  cancerous   disease   of 
uterus  to,  285 

rupture  of  ovarian  cyst  into,  412 

spasm  of,  or  vaginismus,  523 
Vaginitis,  505 

granular,  510 
Vesico-vaginal  fistula,  492 

treatment  previous  to  operation  for,  493 
Vulva,  eczema  of,  519 

puritus  of,  521 

follicular  inflammation  of,  529 

gangrenous  inflammation  of,  517 

tertiary  syphilis  of,  529 

lupus  of,  531 

cancer  of,  535 

Wolffian  bodies,  cysts  of,  393 
often  remain  stationary,  407 

Zwanck,  his  pessary  described,  148 


HEN^RY     C.    LE^'S 

(late  lea  *  blanchard's) 

OX_i.i^SSIini:Bj3     O..^T-A.X_.00  XJEl 

OF 

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letters.     Address, 

HENRY  C.  LEA, 

Nos.  706  and  708  Saxsom  St.,  Puiladklpiha,  Pa. 


Henry  C.  Lea's  Publications — {Dictionaries). 


T\UNGLISON  {ROBLED,  31.  D., 

"^  Prnfessor  of  Institutes  of  Medicine  in  Jeffetson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;   A  Dictionary  of  Medical  Science:   Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;   Formulae  for 
OflBcinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  ot 
the  Terms,  and  the  French  and  other  Synonyraes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.    Thoroughly  Revised,  and  very  greatly  Modified  and  Augmented 
In  one  very  large  and  handsome  royal  octavo  volume  of  1048  double-coluraned  pages,  in 
small  type  ;  strongly  done  up  in  extra  cloth,  $6  00  ;  leather,  raised  bands,  $6  75. 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.     Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken.     The  mechanical  exe- 
cution of  this  edition  will  be  found  greatly  superior  to  that  of  previous  impressions.    By  enlarging 
the  size  of  the  volume  to  a  royal  octavo,  and  by  the  emjiloyment  of  a  small  but  clear  type,  on 
extra  fine  paper,  the  additions  have  been  incorporated  without  materially  increasing  the  bulk  of 
the  volume,  and  the  matter  of  two  or  three  ordinary  octavos  has  been  compressed  into  the  space 
of  one  not  unhandy  for  consultation  and  reference. 
It  wonld  be  a  work  of  supererogation  to  bestow  a        It  Is  nndonbtedly  the  most  complete  and  useful 


word  of  praise  upon  this  Lexicon.  We  can  only 
wonder  at  the  labor  expended,  for  whenever  we  refer 
to  its  pages  for  information  we  are  seldom  di.iap- 
polnted  in  finding  all  we  desire,  whether  it  be  in  ac- 


medical  dictionary  hitherto  published  in  this  country. 
— Qhicayo  Med.  Examiner,  February,  l.sg.O. 

What  we  take  to  be  decidedly  the  betit  medical  dic- 
tionary in  the  English  language.    The  present  edition 


cuntuation,  etymology,  or  definition  of  terms.— iV«M»  ,  |„  brought  fully  up  to  the  advanced  state  of  science 
Turk  MedicalJournal,  November,  1S6j.  p^^r  many  a  long  year  "Duuglison"  has  been  at  our 

It  would  be  mere  waste  of  words  in  us  to  express  I  elbow,  a  constant  companion  and  friend,  and  we 
eur  admiration  of  a  work  which  is  so  universally  |  greet  him  in  his  replenislied  and  improved  form  with 
and  deservedly  appreciated.     The  most  admirable  I  especial  satisfaction. — Pacific  Med.  and  Unrg.  Jour- 


work  of  its  kiud  in  the  English  language.  As  a  book 
of  reference  it  is  invataable  to  the  medical  practi- 
tioner, and  in  every  instance  that  we  have  turned 
over  its  pages  for  information  we  have  been  charmed 
by  the  clearness  of  language  and  the  accuracy  of 
detail  with  which  each  abounds.  We  can  most  cor- 
dially and  confidently  commend  it  to  oar  readers. — 
Glasgow  Medical  Journal,  January,  1866. 

A  work  to  which  there  is  no  ^ual  in  the  English 
language. — Edinburgh  Medical  Journal. 

It  is  something  more  than  a  dictionary,  and  some- 
tbing  less  than  an  eacyclopsedia.  This  edition  of  the 
well-known  work  is  a  great  improvement  on  its  pre- 
decessors. The  book  is  one  of  the  very  few  of  wliich 
it  may  be  said  with  truth  that  every  medical  man 
should  possess  it. — London  Medical  Times,  Aug.  26, 
lSt>5. 

Few  works  of  the  class  exhibit  a  grander  monument 
«f  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sulHcieul  to  testify  to  its 
c-efalness,  and  to  the  great  service  conferred  by  Dr. 
Eobley  Dunglison  on  the  prof9.<.>(ion,  and  indeed  on 
others,  by  its  issue. — London  Lancet,  May  13,  1865. 

The  old  edition,  which  is  now  superseded  by  the 


nal,  June  27,  1S6.5. 

This  is,  perhaps,  the  book  of  all  others  which  the 
physician  or  surgeon  should  have  on  his  shelves.  It 
is  more  needed  at  the  present  day  than  a  few  years 
back. — Canada  Med.  Journal,  July,  1865. 

It  deservedly  stands  at  the  head,  and  caiinot  be 
surpassed  in  excellence. — Buffalo  Med.  ana  Surg. 
Journal,  April,  1865. 

We  can  sincerely  commend  Dr  Dnnglison's  work 
as  most  thorough,  scientific,  and  accurate.  We  have 
tested  it  by  searching  its  pages  for  new  terms,  which 
have  abounded  so  much  of  late  in  medical  nomen- 
clature, and  our  search  has  been  successful  in  every 
instance.  We  have  been  particularly  struck  with  the 
fulness  of  the  synonymy  and  the  accuracy  of  the  de- 
rivation of  words.  It  is  as  necessary  a  work  to  every 
enlightened  physician  as  Worcester's  English  Dic- 
tionary is  to  every  one  who  would  keep  up  his  know- 
ledge of  the  English  tongue  to  the  standard  of  the 
present  day.  It  is,  to  our  mind,  the  most  complete 
work  of  the  kind  with  which  we  are  acquainted. — 
Boston  Med.  and  Surg.  Journal,  June  22,  186.5. 

We  are  free  to  confess  that  we  know  of  no  medical 
dictionary  more  complete ;  no  one  better,  if  so  well 


B«w,  has  been  universally  looked  upon  by  the  medi-  i  adapted  for  the  use  of  the  student;  no  one  that  may 
ral  profession  as  a  work  of  immense  research  and    ^e  consulted  with  more  satisfaction  by  the  medical 


treat  value.  The  new  has  increased  usefulness;  for 
medicine,  in  all  Its  branches,  has  been  making  such 
progress  that  many  new  terms  and  subjects  have  re- 
eeutly  been  introduced  :  all  of  which  may  be  found 
fully  defined  in  the  pre.sent  edition.  We  know  of  no 
other  dictionary  in  the  English  language,  that  can 
bear  a  comparison  .with  it  in  point  of  completeness  of 
subjects  and  accuracy  of  statement. — N.  Y.  Drug- 
gists' Circular,  1865. 

For  many  years  Dnnglison's  Dictionary  has  been 
the  standard  book  of  reference  with  most  practition- 
ers in  this  country,  and  we  can  certainly  commend 

this  work  to  the  renewed  confidence  and  regard  of  ,  in  the  English  language  for  accuracy  and  extent 
oar  readers. — Cincinnati  Lancet,  April,  1S65.  !  references. — London  Medical  Gazette. 


practitioner. — Am.  Jour.  Med.  Sciences,  April,  1865. 

The  value  of  the  present  edition  has  been  greatly 
enhanced  by  the  introduction  of  new  subjects  and 
terms,  and  a  more  complete  etymology  and  accentua- 
tion, which  readers  the  work  not  only  satisfactory 
and  desirable,  but  Indispensable  to  the  physician. — 
Chicago  Med.  Journal,  April,  1865. 

Jfo  intelligent  member  of  the  profession  can  or  will 
be  without  it. — St.  Louis  Med.  and  Surg.  Journal, 
April,  1865. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 


TTOBLYN  {RICHARD  D.),  M.D. 

A  DICTIOXARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  A  new  American  edition,  revised,  with  numerous 
a^lditions,  by  Isaac  Hats,  M.D.,  Editor  of  the  "American  Journal  of  the  Medical 
Sciences."  In  one  large  royal  12mo.  volume  of  over  600  double-columned  pages;  extra 
eloth,  *1  50  ;  leather,  S2  00. 
It  is  the  best  book  of  deflulti.'n.-  we  have,  aad  oright  always  to  be  npon  the  etadeat'e  Xa.'iii^.— Southern 
Med  and  Surg  Journal. 


Henry  C.  Lea's  Publications — (Manuals). 


■^EILL  [JOHN),  M.D., 


and     OMITH  [FRANCIS  G.),  M.D. 


Pro/,  of  the  Institutes  of  Medicine  in  the  Univ.  of  Penna. 


AN    ANALYTICAL    COMPENDIUM   OF   THE   VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  I2mo. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  extra  cloth,  $4 ;  strongly  bound 
in  leather,  with  raised  bands,  $4  75. 


The  Compend  of  Drs.  Neill  and  Smith  is  incompara- 
bly the  most  valuable  work  of  its  class  ever  published 
Hn  this  country.  Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetries,  Materia  Medica, 
and  Chemistry  into  a  single  manual;  but  the  opera- 
tion has  sig^Uy  failed  in  the  hands  of  all  up  to  the 
advent  of"  Neill  and  Smith's"  volume,  which  is  quite 
a  miracle  of  success.  The  outlines  of  the  whole  are 
admirably  di-awn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  .student  of  every  class. — N.  0.  Med.  and  Surg. 
Journal. 

This  popular  favorite  with  the  student  Is  so  well 
known  that  it  requires  no  more  at  the  hands  of  a 
medical  editor  than  the  annunciation  of  a  new  and 
improved  edition.  There  is  no  sort  of  comparison 
between  this  work  and  any  other  on  a  similar  plan, 
and  for  a  similar  object. — Nash.  Journ.  of  Medicine. 
There  are  but  few  students  or  practitioners  of  me- 
dicine unacquainted  with  the  former  editions  of  this 
anas^umiog  though  highly  instructive  work.  The 
whole  science  of  medicine  appears  to  have  been  sifted, 
as  th<3  goM-bearing  sands  of  El  Dorado,  and  the  pre- 
cious facts  treasured  up  in  this  little  volume.  A  com- 
plete portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companion. —  West- 
ern Lancet. 

To  compress  the  whole  science  of  medicine  in  less 
than  1,000  pages  is  an  impossibility,  but  we  think  that 
the  book  before  us  approaches  as  near  to  it  as  is  pos- 
sible. Altogether,  it  is  the  best  of  its  class,  and  has 
met  with  a  deserved  success.  As  an  elementary  text- 
book for  students,  it  has  been  useful,  and  will  con- 
tinue to  be  employed  in  the  examination  of  private 
classes,  whilst  it  will  often  be  referred  to  by  the 
eoaotry  practitioner. —  Va.  Med.  Juurnal. 


As  a  handbook  for  students  It  Is  Invaluable,  con- 
taining in  the  most  condensed  form  the  established 
facts  and  principles  of  meilicine  and  its  collateral 
sciences. — N.  H.  Journal  of  Medicine. 

In  the  rapid  course  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa^ 
mination,  a  compend  is  not  only  valuable,  but  it  is 
almost  a  sine  qua  non.  The  one  before  us  is,  in  most 
of  the  divisions,  the  most  unexceptionable  of  all  books 
of  the  kind  that  we  know  of.  The  newest  and  sound- 
est doctrines  and  the  latest  improvements  and  dis- 
coveries are  explicitly,  though  concisely,  laid  before 
the  student.  Of  course  it  is  useless  for  us  to  recom- 
mend it  to  all  last  course  students,  but  there  is  a  clans 
to  whom  we  very  sincerely  commend  this  cheap  boob 
as  worth  its  weight  in  silver — that  class  is  the  gradn- 
I  ates  in  medicine  of  more  than  ten  years'  standing, 
who  have  not  studied  medicine  since.  They  will 
perhaps  find  out  from  it  that  the  science  is  not  ex- 
actly now  what  it  was  when  they  left  it  oif. — The 
I  Stethoscope. 

I      Having  made  free  use  of  this  volume  in  our  exami- 

I  nations  of  pupils,  we  can  speak  from  experience  in 

j  recommending  it  as  an  admirable  compend  for  stu- 

1  dents,  and  especially  useful  to  preceptoi-s  who  exaio- 

1  ine  their  pupils.     It  will  save  the  teacher  much  lab<ir 

]  by  enabling  him  readily  to  recall  all  of  the  points 

upon  which  his  pnpils  should  be  examined.     A  work 

of  this  sort  should  be  in  the  hands  of  every  one  who 

takes  pupils  into  his  office  with  a  view  of  examining 

I  them ;  and  this  is  unquestionably  the  best  of  its  class. 

Let  every  practitioner  who  lias  pupils  provide  himself 

with  it,  and  he  will  find  the  labor  of  refreshing  hi« 

knowledge  so  much  facilitated  that  he  will  be  able  to 

do  justice  to  his  pupils  at  very  little  cost  of  time  or 

trouble  to  himself. — Transylvania  Med.  Journal. 


jrUDLOW  [J.L.l  M.D. 


A   MANUAL   OF   EXAMINATIONS   upon   Anatomy,   Phy&iology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  la  one  handsome  royal 
12mo.  volume  of  816  large  pages,  extra  cloth,  $3  25 ;  leather,  $3  75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  surt- 
able  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


We  know  of  no  better  companion  for  the  student 
during  the  hours  spent  in  the  lecture-room,  or  to  re- 
fresh, at  a  glance,  his  memory  of  the  various  topics 
crnmmed  into  his  head  by  the  various  professors  to 
whom  he  is  compelled  to  listen. — Western  Lancet. 

As  it  embraces  the  whole  range  of  medical  studies 
it  is  necessarily  volumiaous,  containing  816  large 
duodecimo  pages.  After  a  somewhat  careful  exami- 
nation of  its  contents,  we  have  formed  a  much  more 
favorable  opinion  of  it  than  we  are  wont  to  regard 
«uch  works.  Although  well  adapted  to  meet  the  wants 


of  the  student  in  preparing  for  his  final  examination, 
it  might  be  profitably  consulted  by  the  practitioner 
also,  who  is  most  apt  to  become  rusty  in  the  very  kind 
of  details  here' given,  and  who,  amid  the  hurry  of  his 
daily  routine,  is  but  too  prone  to  neglect  the  study  of 
more  elaborate  works.  The  possession  of  a  volume 
of  tl^s  kind  might  serve  as  an  inducement  for  him  ut 
seize  the  moment  of  excited  curiosity  to  inform  him- 
self on  any  subject,  and  which  is  otherwise  too  ofttn 
allowed  to  pass  unimproved. — St.  Louis  Med.  and 
Surg.  Journal. 


/TANNER  {THOMAS  HAWKES),  M.  D., 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.  Third  American,  from  the  second  enlarged  and  revised  English  edition.  T« 
which  is  added  The  Code  of  Ethics  of  the  American  Medical  Association.  In  one  hand- 
some volume  12mo.      (Preparing  for  ear(^  piMication.) 

This  work,  after  undergoing  a  very  thorough  revision  at  the  hands  of  the  author,  may  now  be 
expected  to  appear  shortly.  The  title  scarcely  affords  a  proper  idea  of  the  range  of  subjects  em- 
braced in  the  volume,  as  it  contains  not  only  very  full  details  of  din^nostic  symptoms  j)roperly 
classified,  but  also  a  large  amount  of  information  on  matters  of  every  day  practical  iiuport.tni-e 
not  usually  touched  upon  in  the  sv«t*»natic  wnrV^    or  8C4itt«red  through  many  different  volumes. 


Henry  C.  Lea's  Publications — {Anatomy). 


riRAY  {HENRY),  F.R.S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,    DESCRIPTIVE    AND    SURGICAL.'     The  Drawings  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissec- 
tions jointly  by  the  Author  and  Dr.  Carter.     Second  American,  from  the  second  revised 
and  improved  London  edition.     In  one  magnificent  imperial  octavo  volume,  of  over  800 
pages,  with  388  large  and  elaborate  engravings  on  wood.     Price  in  extra  cloth,  $6  00; 
leather,  raised  bands,  $7  00. 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  natui^,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.    They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
e.ssentinl  use  to  all  physicians  who  receive  students  in  their  ofiBces,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Notwithstanding  its  exceedingly  low  price,  the  work  will  be  found,  in  every  detail  of  mechanical 
execution,  one  of  the  handsomest  that  has  yet  been  offered  to  the  American  profession  ;  while  the 
careful  scrutiny  of  a  competent  anatomist  has  relieved  it  of  jrhatever  typographical  errors  existed 
in  the  English  edition. 

Thus  it  i.s  that  book  after  book  makes  the  labor  of 
the  student  easier  than  before,  and  since  we  have 
seen  Blanchard  &  Lea's  new  edition  of  Gray's  Ana- 
tomy, certainly  the  finest  woi-k  of  the  kind  now  ex- 
taut,  we  would  fain  hope  that  the  bugbear  of  loedical 
students  will  lose  half  its  horrors,  and  this  necessary 
foundation  of  physiological  science  will  be  much  fa- 
cilitated and  advanced.— .W".  0.  Med.  New«.  . 


The  various  points  illustrated  are  marked  directly 
on  the  structure;  that  is,  whether  it  be  muscle,  pro- 
ces.s,  artery,  nerve,  valve,  etc.  etc. — we  say  each  point 
is  distinctly  marked  by  lettered  engravings,  so  that 
the  student  perceives  at  once  each  point  described  as 
reiidily  as  if  pointed  out  on  the  subject  by  the  de 


and  with  scarce  a  reference  to  the  printed  text.  The 
surgical  application  of  the  various  regions  is  also  pre- 
sented with  force  and  clearness,  impres-sing  upon  the 
student  at  each  step  of  his  research  all  the  important 
relations  of  the  structure  demonstrated. — Cincinnati 
Lnncet. 

This  is,  we  believe,  the  handsomest  book  on  Aaa- 
tomy  as  yet  published  in  our  language,  and  bids  fair 
to  become  in  a  shoi't  time  the  standard  text-book  of 
our  colleges  and  studies.  Students  and  practitioners 
will  alike  appreciate  this  book.  We  predict  for  it  a 
bright  career,  aud  are  fully  prepared  to  endorse  the 
statement  of  the  Limdon  Lnncet,  that  "We  are  not 
acquainted  with  any  work  in  any  language  which 
can  talie  equal  rank  with  the  one  before  us."   Paper, 


iiionstrator.  Most  of  the  illustrations  are  thus  ren-  printing,  binding,  all  are  excellent,  and  we  feel  that 
dered  exceedingly  satisfactory,  and  to  the  physician  a  grateful  profession  will  not  allow  the  publishers  to 
they  serve  to  refresh  the  memory  with  great  readiuessi  go  unrewarded. — NashvUle  Med.  and  Surg.  Journal. 


i^MITH  {HENRY H.),  M.D.,         and     TJORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  Ac.  Late  Prof,  of  Anatomy  in  the  Univ.  o/Penna.,  Ac- 

AN    ANATOMICAL    ATLAS,  illustrative  of  the   Structure  of  the 

Human  Body.     In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred 
and  fifty  beautiful  figures.     $4  50. 

The  plan  of  this  Atlas,  which  renders  it  so  pecn-  1  the  kind  that  has  yet  appeared;  and  we  must  add. 
Jiarly  convenient  for  the  student,  and  its  superb  ar-  |  the  very  beautiful  manner  in  which  it  is  "got  up'* 
tistical  execution,  have  been  already  pointed  out.  Weils  so  creditable  to  the  country  as  to  be  flattering  to 
must  congratulate  the  student  upon  the  completion     oar  national  pride. — American  Medical  J<mrnal. 
of  tliis  Atlas,  as  It  is  the  most  convenient  work  of  I 


TJORNER  {WILLIAM  E.),  M.D., 

SPECIAL  ANATOMY  AND  HISTOLOGY.    Eighth  edition,  exten- 

sively  revised  and  modified.     In  two  large  octavo  volumes  of  over  1000  pages,  with  more 
than  300  wood-cuts ;  extra  cloth,  $6  00. 


e HARPEY  { WILLIAM),  M.D.,     cmd       Q  UAIN  {JONES  §•  RICHARD). 
HUMAN  ANATOMY.  Revised,  with  Notes  and  Additions,  by  Joseph 

Leidv,  M.D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two 
large  octavo  volumes,  of  about  1300  pages,  with  511  illustrations;  extra  cloth,  $6  00. 
The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the  sabject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 


ALLEN  {J.  M.),  M.D. 
THE  PRACTICAL  ANATOMIST;  or.  The  Student's  Guide  in  the 

Dissecting  Room.     With  266  illustrations.     In  one  very  handsome  royal  12mo.  volume, 
of  over  600  pages ;  extra  cloth,  $2  06. 
One  of  the  most  useful  works  upon  the  subject  ever  written. — Hedioal  Examinet. 


Henry  C.  Lea's  Publications — (Anatomy). 


ryiLSON  [ERASMUS),  F.R.S. 


A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.     A  new 

and  revised  American,  from  the  lajt  and  enlarged  English  edition.     Edited  by  W.  H.  Qo- 
BRECHT,  M.  D.,  Professor  o  ;'3tneral  and  Surgical  Anatomy  in  the  Medical  College  of  Ohio. 
Illustrated  with  thre*  iinndred  and  ninety-seven  engravings  on  wood.     In  one  large  and 
handsome  octavo  volume,  of  over  fiOO  large  pages;  extra  cloth,  $4  00;  leather,  $5  00. 
The  publisher  trusts  that  the  well-earned  rejjutation  of  this  long-established  favorite  will  be 
more  than  maintained  by  the  present  edition.     Besides  a  very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Ana- 
tomy.    The  amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  fact  that 
the  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type 
and  an  enlarged  page  requisite  to  keep  the  volume  within  a  convenient  size.     The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.    The  editor 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  incieaped 
the  number  of  illu.strations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance. 

■nr  THE  SAME  AUTHOR.  ~ 

THE  DISSECTOR'S   MANUAL;   or,  Practical  and  Surgical  Ana- 

TOMY.  Third  American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and 
rearranged  by  William  Hunt,  M.  D.,  late  Demonstrator  of  Anatomy  in  the  University  of 
Pennsylvania.  In  one  large  and  handsome  royal  12mo.  volume,  of  582  pages,  with  164 
illustrations;  extra  cloth,     %1  00. 


TTODGES,  [RICHARD  M.),  M.D., 

-*-*  Late  Duf/ionstratar  of  Anntomi/  in  the  Medi/dl  Department  of  Harvard  Univfrnity. 

PRACTICAL  DISSECTIONS.     Secorrl  Edition,  thoroughly  revised.     In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00.  (Just  Issued.) 
The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  course  of  dissections.  The  author  ha!< 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subject  in  the  form  which  muny  year.«' 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
the  favor  with  which  it  has  heretofore  been  received. 


JJACLISE  [JOSEPH). 

SURGICAL   ANATOMY.      By  Joseph   Maclise,  Surgeon.     In  one 

volume,  very  large  imperial  quarto:  with  68  large  and  splendid  plates,  drawn  in  the  bet^t 
style  and  beautifully  colored,  containing  1^0  figures,  many  of  them  the  size  of  life;  together 
with  copious  explanatory  letter-press.      Strongly  and  handsomely  bound  in  extra  cloth. 
Price  $14  00. 
As  no  complete  work  of  the  kind  has  heretofore  been  published  in  the  English  language,  the 
present  volume  will  supply  a  want  long  felt  in  this  country  of  nn  accurate  and  comprehensive 
Atlas  of  Surgical  Anatomy,  to  which  the  student  and  practitioner  can  at  all  times  refer  to  ascer- 
tain the  exact  relative  positions  of  the  various  portions  of  the  human  frame  towards  each  other 
and  to  the  surface,  as  well  as  their  abnormal  deviations.     The  importance  of  .xuch  a  work  to  the 
Ptudent,  in  the  absence  of  anatomical  material,  and  to  practitioners,  either  for  consultation  in 
emergencies  or  to  refresh  their  recollections  of  the  dissecting  room,  is  evident.     Notwithstanding 
the  large  size,  beauty  and  finish  of  the  very  numerous  illustrations,  it  will  be  observed  that  the 
price  is  so  low  as  to  place  it  within  the  reach  of  all  members  of  the  profession. 

We  know  of  no  work  on  surgical  anatomy  which  ,  refreshed  by  those  clear  and  distinct  dissections, 
e<tn  compete  with  it. — Lancet.  j  wliich  every  one  niu.-it  appreci«t«>  who  has  h  particle 

The  work  of  Maclise  on  surgical  anatomy  Is  of  the  "^  enthusiasm.  The  English  medical  press  has  quite 
highest  value.  In  some  respects  it  is  the  best  puhli-  exlmusteil  the  words  of  pmise,  in  recommending  this 
CHtion  of  its  kind  we  have  seen,  and  is  worlhr  of  a  admirable  treatise.  Those  who  have  any  carioeiiy 
place  in  the  libiary  of  any  medical  man,  while  the  f," /'"'^"''y-  '°  reference  t<i  the  perlectibility  of  the 
student  could  scarcely  make  a  belter  in  veslmont  than  '  lllnographic  art  in  dohnealmg  the  complex  mochau- 
tiiis.—Tlie  WesUrnJoumnlof  Medicineand  Hurgery.  1  ''*™  "f  "i«  human  b.idy.  i»ie  iuvited  to  examine  our 

specimen   copy.      If  anything  will   Induce  surgeons 

No  such  lithographic   lUustralions  of  surgical  re-     and  students  to  patronize  a  book  of  such  rare  valfip 

gions  have  hitherto,  we  think,  been  given.     While  [  and  everyday  importance  to  them,  it  will  be  a  survey 

the  operator  Is  shown  every  vessel  and  nerve  where  I  of  the  avtisiical  skill  exhibited  in  these  fac-eiuiiles  of 

&u  operation  in  contemplated,  the  exact  auatomUt  is  \  nature. — B'tnton  3ftd.  and  Sury.  J<iurnal. 


P 


EASLEE  (E.  /?.),  M.D., 

Pr'ifcsxitr  of  Anatomy  unit  PUyitinlogy  in  DnrtinoxUh  Med.  CnlUgf^  If.  H. 

HUMAN  HISTOLOGY,  in  it.s  relations  to  Anatomy,  Physiology,  and 

Pathology;  for  the  use  of  medical  students.     AVifh  four  bumlred  and  thirty-four  illugtra- 
tAuaa.     Ic  one  handsome  octavo  volume  of  over  tjOC  pages,  extra  cloth.     $3  75. 


Henry  C.  Lea's  Publications — {Physiology). 


JITAESITALL  (JOHN),  F.  R.  S. 

•^  Professor  of  Surgery  in  University  College,  London,  Ac. 

OUTLINES  OF  PHYSIOLOGY,  HUMAN  AND  COMPARATIVE. 

With  Additions  by  Frai^cis  Gurnet  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi- 
cine in  the  University  of  Pennsylvania,  &c.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  about  900  pages.     {Preparing/or  early  PnbUcation.) 

tnde  and  skill  in  expounding  it,  qualify  a  man  U> 
write  an  educational  work,  Mr.  Marshall's  treatise 
might  be  reviewed  favorably  withont  even  opening 


We  may  now  congratulate  him  on  having  com- 
pleted the  latest  as  well  as  the  best  summary  of  mod- 
ern physiological  science,  both  human  and  compara- 
tive, with  which  we  are  acquainted.  To  speak  of 
this  work  in  the  terms  ordinarily  used  on  such  occa- 
sions would  not  be  agreeable  to  ourselves,  and  would 
fail  to  do  justice  to  its  author.  To  write  such  a  book 
requires  a  varied  and  wide  range  of  knowledge,  con- 
siderable power  of  analysis,  correct  judgment,  skill 
in  arrangement,  and  conscientious  spirit.  It  must 
have  entailed  great  labor,  but  now  that  the  ta.'k  has 
been  fulfilled,  The  book  will  prove  not  only  invaluable 
t«  the  student  of  medicine  and  surgery,  but  service- 
able to  all  candidates  in  natural  science  examinations, 
to  teachers  in  schools,  and  to  the  lover  of  nature  gene- 
rally. In  conclusion,  we  can  only  express  the  con- 
viction that  the  merits  of  the  work  will  command  for 
it  that  success  which  the  ability  and  vast  labor  dis- 
played in  its  produciion  so  well  deserve.— LoncioH 
Lancet,  Feb.  22,  ISbS. 

If  the  possession  of  knowledge,  and  peculiar  apti- 


the  covers.  There  are  few,  if  any,  roorenccomplished 
anatomists  and  physiologists  than  the  distinguished 
professor  of  surgery  at  IFnirersity  College  ;  and  he 
has  long  enjoyed  the  highest  reputation  as  a  teacher 
of  physiology,  possessing  remarkable  powers  of  clear 
exposition  and  graphic  illustration.  It  is  only  re- 
markable that  Mr.  Marshall  has  allowed  so  long  a 
time  to  elapse  before  producing  a  text-book  after  his 
own  heart.  The  plan  of  this  book  differs  in  many 
respects  from  that  of  existing  educational  books  ; 
the  science  of  human  physiology  being  treated  in 
wider  and  more  constant  reference  to  chemistry, 
physics,  and  comparative  anatomy  and  physiology. 
There  can  be  no  question,  we  think,  that  this  is  the 
most  satisfactory,  philosophic,  and  frnitfnl  mode  of 
teaching  physiology.  We  have  rarely  the  pleasure 
of  being  able  to  recommend  a  text-book  so  unreserv- 
edly as  this. — British  Med.  Journal,  Jan.  25,  1S68. 


c 


'ARP ENTER  [WILLIAM  B.),  M.D.,  F.R.S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 

cations  to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  new 
American  from  the  last  and  revised  London  edition.  With  nearly  three  hundred  illnstrationa. 
Edited,  with  additions,  by  Francis  Gurnet  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  Ac.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed ;  extra  cloth,  $5  50 ;  leather,  raised 
bands,  $6  60. 

We  doabt  not  it  is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  lii 
our  colleges. — Virginia  MeAical  Journal. 


The  highest  compliment  that  can  be  extended  to 
this  great  work  of  I)r.  Carpenter  Is  to  call  attention 
to  this,  another  new  edition,  which  the  favorable 
regard  of  the  profession  has  called  for.  Carpenter  Is 
the  standard  authority  on  physiology,  and  no  physi- 
cian or  medical  student  will  regard  his  library  as 
complete  without  a  copy  of  \\..— Cincinnati  Med.  Ob- 
si^rver. 

With  Dr.  Smith,  we  confidently  believe  "that  the 
present  will  more  than  sustain  the  enviable  reputa- 
tion already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language."  We  know  of  none 
from  the  pages  of  which  a  satisfactory  knowledge  of 
tlio  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  up  the  study  of  physiology  iu  its  reference  to 
the  institutes  and  practice  of  medicine. — Am.  Jour. 
Med.  Sciences.  t 


We  have  so  often  spoken  in  terms  of  high  com- 
mendation of  Dr.  Carpenter's  elaborate  work  on  hu- 
man physiology  that,  in  announcing  a  new  edition, 
it  is  unnecessary  to  add  anything  to  what  has  hereto- 
fore been  said,  and  especially  is  this  the  case  since 
every  intelligent  physician  is  as  well  aware  of  the 
character  and  merits  of  the  work  as  we  ourselves  are. 
— St.  Louis  Med.  and  Surg.  Journal. 

The  above  is  the  title  of  what  is  emphatically  th>> 
great  work  on  physiology ;  and  we  are  conscious  that 
it  would  be  a  useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
inllnence,  that  it  is  our  aulhorUy. — Atlanta  Moi. 
Journal. 


B 


r  THE  SAME  AUTHOR. 


PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.    New  Ameri- 

can   from  the  Fourth  and  Revised  London  Edition.     In  one  large  and  haml.some  octavo 
volume,  with  over  three  hundred  beautiful  illustrations     Pp.  752.    Extra  cloth,  $5  00. 
As  a  complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomes 
a  necessity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  is  offered  places  it 
within  the  reach  of  all. 
or  THE  SAME  AUTHOR. 

THE  MICROSCOPE  AND   ITS  REVELATIONS.     Illustrated  by 

four  hundred  and  thirty-four  beautiful  engravings  on  wood.     In  one  large  and  very  hand- 
some octavo  volume,  of  724  pages,  extra  cloth,  $5  25. 


jriRKES  {  WILLIAM  SENHOUSE),  M.  D., 

A  MANUAL  OF  PHYSIOLOGY.     A  new  American  from  the  third 

and  improved  London  edition . 
some  royal  12mo.  volume.     ~ 


With  two  hundred  illustrations.     In  one  large  and  hand- 
Pp.  586.     Extra  cloth,  $2  25  ;  leather,  $2  75. 


It  is  at  once  convenient  in  size,  comprehensive  in 
design,  and  concise  in  statement,  and  altogether  well 
adapted  for  the  purpose  designed. — St.  Louis  Med. 
on/t  Surg.  Journal. 

The  physiological  reader  will  find  it  a  Ho»»t  excel- 


lent guide  in  the -study  of  physiology  in  its  most  ad- 
vanced and  perfect  form.  The  author  has  shows 
himself  capable  of  giving  details  sufficiently  ample 
in  a  condensed  and  concentrated  shape,  on  a  science 
in  which  it  is  necessary  at  once  to  be  correct  and  not 
lengthened. — Edinburgh  Med.'ttnd  Surg.  J'/urnoL 


Henry  C.  Lea's  Publications — {Physiology). 


f)ALTON  [J.  C),  M.D., 

-*--'  Professor  of  PhysioUiyy  in  the  College  of  Physicians  and  Surgeons,  New  York,  &c. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY,  Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Fourtli  edition,  revised,  with  nearly  three  hun- 
dred illustrations  on  wood.  In  one  very  beautiful  octavo  volume,  of  about  700  pages,  extra 
cloth,  $5  25  ;  leather,  $6  25.     {Now  Ready.) 

From,  tlie  Prefo.i'e  to  the  Ni»o  Edition. 
"  The  progress  made  by  Physiology  and  the  kindred  Sciences  during  the  last  few  years  has  re- 
quired, for  the  present  edition  of  this  work,  a  thorough  and  extensive  revision.  This  progress 
has  not  consisted  in  any  very  striking  single  discoveries,  nor  in  a  decided  revolution  in  any  of 
the  departments  of  Physiology  ;  but  it  has  been  marked  by  great  activity  of  investigation  in  a 
multitude  of  different  directions,  the  combined  results  of  which  have  not  failed  to  impress  a  new 
character  on  many  of  the  features  of  physiological  knowledge.  ...  In  the  revision  and 
correction  of  the  present  edition,  the  author  has  endeavored  to  incorporate  all  such  improve- 
ments in  physiological  knowledge  with  the  mass  of  the  text  in  such  a  manner  as  not  essentially 
to  alter  the  structure  and  plan  of  the  work,  so  far  as  they  have  been  found  adapted  to  the  wants 
and  convenience  of  the  reader.  .  .  .  Several  new  illustrations  are  introduced,  some  of  them 
as  additions,  others  as  improvements  or  corrections  of  the  old.  Although  all  parts  of  the  book 
have  received  more  or  less  complete  revision,  the  greatest  number  of  additions  and  changes  were 
required  in  the  Second  Section,  on  the  Physiology  of  the  Nervous  System." 


The  advent  of  the  first  editiou  of  Prof.  Dalton's 
Physiology,  about  eight  years  ago,  marked  a  new  era 
in  the  sludy  of  physiology  to  the  American  student. 
Under  Dalton'e  skilful  luanagement,  physiological 
science  threw  off  the  long,  loose,  ungainly  garments 
of  probability  and  surmise,  in  which  it  had  been  ar- 
rayed by  most  artists,  and  came  among  us  smiling 
and  attractive,  in  the  beautifully  tinted  and  closely 
fitting  druss  of  a  demonstrated  science.  It  was  a 
stroke  of  genius,  a&  well  as  a  result  of  erudition  and 
talent,  that  led  Prof.  Dalton  to  present  to  the  world 
a  work  on  physiology  at  once  brief,  pointed,  and  com- 
prehensive, and  which  exhibited  plainly  in  letter  and 
drawings  the  basis  upon  which  the  conclusions  ar- 
rived at  rested.  It  is  no  disparagement  of  the  many 
excellent  works  on  physiology,  published  prior  to 
that  of  Dalton,  to  say  that  none  of  them,  either  in 
plan  of  arrangement  or  clearness  of  execution,  could 
be  compared  with  his  for  the  use  of  students  or  gene- 
ral practitioners  of  medicine.  For  this  purpo.se  his 
book  has  no  equal  in  the  English  language. —  Western 
Journal  of  Medicine,  Nov.  18t)7. 

A  capital  text-book  in  every  way.  We  are,  there- 
fore, glad  to  see  it  in  its  fourth  edition.  It  has  already 
been  examined  at  full  length  in  these  columns,  so  that 
we  need  not  now  further  advert  to  it  beyond  remark- 
ing that  both  revision  and  enlargement  have  been 
most  judicious. — Londun  Med.  Times  and  Gazette, 
Oct.  19,  1867.' 

No  better  proof  of  the  value  of  this  admirable 
work  could  be  produced  than  the  fact  that  it  has  al- 
ready reached  a  fourth  edition  in  the  short  space  of 
eight  years.     Possessing  in  an  eminent  degree  the 


merits  of  clearness  and  condensation,  and  being  fully 
brought  up  to  the  present  level  of  Physiology,  it  is 
undoubtedly  one  of  the  most  reliable  text-books 
upon  this  science  that  could  be  placed  in  the  hands 
of  the  medical  student. — Ain.  Journal  Med.  Sciences, 
Oct.  1867. 

Prof.  Dalton's  work  has  such  a  well-established 
reputation  that  it  does  not  stand  in  need  of  any  re- 
commendation. Ever  since  its  first  appearance  it  has 
become  the  highest  authority  in  tlie  English  language ; 
and  that  it  is  able  to  maintain  the  enviable  position 
which  it  has  taken,  the  rapid  exhaustion  of  the  dif- 
ferent successive  editions  is  sufficient  evidence.  The 
present  edition,  which  is  the  fourth,  has  been  tho- 
roughly revised,  and  enlarged  by  the  iucMrporation 
of  all  the  many  important  advances  which  have 
lately  been  made  in  this  rapidly  progressing  science. 
—N.  Y.  Med.  Record,  Oct.  l.j,  1867. 

As  it  stands,  we  esteem  it  the  very  best  of  the  phy- 
siological text-books  for  the  student,  and  the  most 
concise  reference  and  guide-book  for  the  practitioner. 
—N.  Y.  Med.  Journal,  Oct.  1867. 

The  present  edition  of  this  now  standard  work  fully 
sustains  the  high  reputation  of  its  accotnplished  au- 
thor. It  is  not  merely  a  reprint,  but  has  been  faith- 
fully revised,  and  enriched  by  such  additions  as  the 
progress  of  physiology  has  rendered  desirable.  Taken 
as  a  whole,  it  is  unquestionably  the  most  reliable  and 
u.seful  treatise  on  the  subject  that  has  been  issued 
from  the  American  press. — Chicago  Med.  Journal, 
Sept.  1867. 


TkUNGLISON  {ROBLEY),  M.D., 

-*--'  Profe^s-sor  of  InslUtdes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.     Eighth  edition,     Thoronghl^y  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two 
large  and  handsomely  printed  octavo  volumes  of  about doOO  pages,  extra  cloth.     $7  00. 


EHMANN  [C.  G.) 

'  PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  George  E.  Dav,  M.  D.,  F.  R.  S.,  Ac,  edited  by  R.  E.  Rogeus,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustratione 
pelected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendi.K  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  extra  cloth.     $6  00. 


■DY  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY. 


Translated  from  the 


German,  with  Notes  and  Additions,  by  J  CnKSTON  Morris,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samuei,  Jackson,  M.  D.,  of  the  University  of  Ponn,«yl- 
vania.  With  illustrations  on  wood.  In  on©  very  handsome  octavo  volume  of  336  pages 
extra  oloth.     $2  25. 


JVDD  {ROBERT  B.),  M.D.  F.R.S.,  and  JgOWMAN  {W.),  F.R.S. 


THE 


PHYSIOLOGICAL   ANATOMY   AND   PHYSIOLOGY   OF 

MAN.     With  about  three  hundred  large  and  beautiful  illustrations  on  wood.     Complete  in 
one  large  octavo  volume  of  950  pages,  extra  cloth.     Price  $4  75. 


10 


Henry  C.  Lea's  Publications — (Chemistry). 


-DRANDE  (  WM.  T.),  B.  G.L.,  and    /TAYLOR  {ALFRED  S.),  M.D.,  F.R.S. 
CHEMISTRY.     Second  American  edition,  thorouglily  revised  by  Dr. 

Taylok.     In  one  handsome  8vo.  volume  of  764  pages,  extra  cloth,  $5  00  ;  leather,  $6  09. 
(Now  Ready.) 

From  Dr.  Taylor's  Preface. 

"The  revision  of  the  second  edition,  in  consequence  of  the  death  of  my  lamented  colleague, 
has  devolved  entirely  upon  myself.  Every  ch:ipter,  and  indeed  every  page,  has  been  revised, 
and  numerous  additions  made  in  all  parts  of  the  volume.  These  additions  have  been  restricted 
chiefly  to  subjef^ts  having  some  practical  interest,  and  they  have  been  made  as  concise  as  possible, 
in  order  to  keep  the  book  within  those  limits  which  may  retain  for  it  the  character  of  a  Student's 
Manual  " — London,  June  29,  1867. 


A  book  that  has  already  so  established  a  reputa- 
tion, as  has  Brande  and  Taylor's  Ch(»mistry,  can 
hardly  need  a  notice,  save  to  mention  the  additions 
and  improvements  of  the  edition.  Doubtless  tbe 
work  will  long  remain  a  favorite  text-book  in  the 
schools,  as  well  as  a  conveaient  book  of  reference  for 
all.— A',  r.  Medical  Gazette,  Oct.  12,  1S67. 

For  this  reason  we  hail  with  delight  the  republica- 
tion, in  a  form  which  will  meet  with  general  approval 
and  command  public  attention,  of  this  really  valua- 
ble standard  work  on  chemistry — more  particularly 
as  it  has  been  adapted  with  snch  care  to  the  wants  of 
the  general  public.  The  well  known  scholarship  of 
its  aulhor.*,  and  their  extensive  researches  for  many 
ypars  in  experimental  chemistry,  have  been  long  ap- 
preciated in  the  scientific  world,  but  in  this  work  they 
have  been  careful  to  give  the  largest  possible  amount 
of  information  with  the  most  sparing  use  of  technical 
terms  and  phraseology,  so  as  to  furnish  the  reader, 
"whether  a  Ktudeut  of  medicine,  or  a  man  of  the 
world,  with  a  plain  introduction  to  the  science  and 
practice  of  chemistry." — Journal  of  Applitd  Chem- 
istry, Oct.  1867. 


This  second  American  edition  of  an  excellent  trea- 
tise on  cliomioal  science  is  not  a  mere  repnblication 
from  the  Knglish  press,  but  is  a  revision  and  en- 
largomenl  ol  the  original,  under  the  supervision  of 
the  Kurviving  author.  Dr.  Taylor.  The  favorabla 
opinion  expressed  on  the  publication  of  the  former 
edition  of  tliis  work  is  fully  sustained  by  the  present 
revision,  in  which  l>r.  T.  has  increased  the  size  of 
the  volume,  by  an  addition  of  sixty-eight  pages. — Am. 
Journ.  Med.  Scie/icts,  Oct.  lSti7. 

The  Handbook  in  Chemistry  op  the  Student. — 
For  clearness  of  language,  accuracy  of  description, 
extent  of  information,  and  freedom  from  pedantry 
and  mysticism,  no  other  text-book  comes  into  com- 
petition with  it. — The  Lancet. 

The  authors  set  out  with  the  definite  purpose  of 
writing  a  book  which  shall  be  intelligible  to  any 
educated  man.  Thus  conceived,  and  worked  out  iu 
the  most  sturdy,  common-sense  method,  this  book 
gives  in  the  clearest  and  most  summary  method 
possible  all  the  facts  and  doctrines  of  chemistry. — 
Medical  Times. 


nOWAIAN  {JOHN  E.),  M.  D. 


PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

by  C.  L.  Bloxam,  Professor  of  Practical  Chemistry  in  King's  College,  London.  Fourth 
American,  from  the  fourth  and  revised  English  Edition.  In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations,  extra  cloth.     $2  25. 

which  have  come  to  light  since  the  previous  edition 
was  printed.  The  work  is  indispensable  to  every 
student  o/  medicine  or  enlightened  pi-actitioner.  It 
Is  printed  in  clear  type,  and  the  illustrations  ar« 
numerous  and  iutelUgible. — Bontun  Med.  and  Surg. 
Journal. 


The  fourth  edition  of  this  invaluable  text-book  of 
Medical  Chemistry  was  published  in  England  in  (Octo- 
ber of  the  last  year.  The  Editor  has  brought  down 
the  Handbook  to  that  date,  introducing,  as  far  as  was 
compatible  with  the  necessary  conciseness  of  such  a 
work,  all   the  valuable  discoveries  in   tbe  science 


B 


Y  THE  SAME  AUTHOR. 


INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Fourth  American,  from  the  fifth  and  reviseil  London  edition.     With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  extra  cloth.     $2  25.      (Just  Issued.) 


One  of  the  most  complete  manual.s  that  has  for  a 
long  time  been  given  to  the  medical  student. — 
Athenceum. 

We  regard  it  as  realizing  almost  everything  to  be 
desired  in  an  introduction  to  Practical  Chemistry. 


It  is  by  far  the  best  adapted  for  the  Chemical  student 
of  any  that  has  yet  fallen  in  our  way. — Britinh  and 
Foreign  Medico-Chimrgiral  Review. 

The  best  introductory  work  on  the  .subject  with 
which  we  are  acquainted. — Edinburgh  Monthly  Jour. 


QRA HAM  { THOMAS),  F.  R.  S. 


THE   ELEMENTS   OF   INORGANIC   CHEMISTRY,  including  the 

Applications  of  the  Science  in  the  Arts.  New  and  much  enlarged  edition,  by  Hesky 
Watts  and  Robert  Bridges,  M.  D.  Complete  in  one  larcje  and  handsome  octavo  volume, 
of  over  800  very  large  pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth. 
$5  50. 

Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  Ac,  may  be  had 
separate,  cloth  backs  and  paper  sides.     Price  $3  00. 

Prom  Prof.  E.  N.  Hor.ifi>rd,  Harvard  College.         j  afford  to  be  without  this  edition  of  Prof.  Graham's 

It  has.  in  its  earlier  and  less  perfect  editions,  been    Elements.— Si7/im«7i'*  Journal,  March,  IS.iS. 

familiar  to  me,  and  the  excellence  of  its  plan  and  \      From  Pmf.  Wolcott  GihhH,  If.  T.  Free  Acaiicmy, 

the  clearness  and  completeness  of  its  discussions.!      The  work  is  an  admirable  one  in  all  respects,  ana 

have  long  been  my  admiration.  j  ij^  republication   here  cannot  fail  to  exert  a  positive 

No  reader  of  English  works  on  this  science  can  1  influence  upon  the  progress  of  science  in  this  country. 


Henry  C.  Lea's  Publications — (ChemlHtry,  Pharmacy ^&c.).      11 


JpOWNES  [GEORGE],  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY ;   Theoretical  and 

Practical.    With  one  hundred  and  ninety-  -----  - 

M.  D.  In  one  large  royal  I2mo.  volume, 
We  know  of  uo  treatise  iu  the  language  »o  well 
calculated  to  aid  the  student  in  becoming  familiar 
with  the  numerous  facts  in  tlie  intrinsic  science  on 
which  it  treats,  or  one  better  calculated  as  a  text- 
book for  those  attending  Cheinica!  lectures.  *  *  *  * 
The  best  text-book  on  Chemistry  that  has  issued  from 
our  press. — American  Medical  Jonrnnl. 


We  again  most  cheerfully  recommend  it  as  the 
best  text-book  for  students  in  attendance  uponriiem- 
ical  lectures  that  we  have  yet  examined. — III.  and 
Ind.  Med.  and  Surg.  Journol. 

A  first-rate  work  upon  a  first-rate  subject. — 8t. 
Lonis  Med.  and  Surg.  Journal. 

No  manual  of  Chemistry  whicM  we  have  met 
comes  so  near  meeting  the  wants  of  the  beginner. — 
Western  Journal  of  Medicine  and  Surgery. 


seven  illustrations.  Edited  by  Robert  Bridges, 
of  600  pages,  extra  cloth,  §2  00;  leather,  S2  60. 

We  know  of  none  within  the  same  limits  which 
has  higher  claims  to  our  confidence  as  a  college  class- 
book,  both  for  accuracy  of  detail  and  scientific  ar- 
rangement.— Augwita  Medical  Jmirnal. 

We  know  of  no  text-book  on  chemistry  that  we 
would  sooner  recommend  to  the  student  than  this 
edition  of  Prof.  Fownes'  work. — Montreal  Medictel 
Chraninle. 

A  new  and  revised  edition  ofoneofthebest  elemen- 
tary works  on  chemistry  accessible  to  the  Americaa 
and  English  student. — N.  T.  Journal  of  Medical  and 
Collateral  Science. 

We  unhesitatingly  recommend  it  to  medical  stu- 
dents.— N.  W.  Med.  and  Surg.  Journal. 

This  is  a  most  excellent  text-book  for  class  Instruc- 
tion in  chemistry,  whether  for  schools  or  colleges. — 
Sillirnan's  Journal. 


ABEL  AND  BLOXAM'S  HANDBOOK  OF  CHEMIS- 
TRY, Theoretical,  Practical,  and  Technical.  In  one 
vol.  8vo.  of  662  pages,  extra  cloth,  $t  .W. 

GARDNER'S  MEDICAL  CHEMISTRY.  1vol.  12mo., 
with  wood-cuts  ;  pp.  396,  extra  cloth,    $1  00. 


KNAPP'S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions,  by  Prof  Waltkr  R.  Johnson.  In  two 
very  handsome  octavo  volumes,  with  500  wood 
engravings,  extra  elolh,  $6  00. 


pARRISH  {ED  WARD), 

Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulse  and 
Prescriptions.     Third  Edition,  greatly  improved.     In  one  handsome  octavo  volume,  of  860 
pages,  with  several  hundred  illustrations,  extra  cloth.     $6  00. 
The  immense  amonnt  of  practical  information  condensed  in  this  volume  may  be  estinjated  from 
the  fact  that  the  Index  contains  about  4700  items.      Under  the  head  of  Acids  there  are  312  refer- 
ences ;  under  Emplastrum,  36 ;  Extracts,  159 ;  Lozenges,  25 ;  Mixtures,  65  ;  Pills,  66 ;  Syrups, 
131;  Tinctures,  138;   Unguentum,  67,  &c. 


We  have  examined  this  large  volume  with  a  good 
deal  of  care,  and  find  that  the  author  has  completely 
exhausted  the  subject  upon  which  he  treats;  a  more 
complete  work,  we  think,  it  would  be  impossible  to 
find.  To  the  student  of  pharmacy  the  work  is  indis- 
pensable ;  indeed,  so  far  as  we  know,  it  is  the  only  one 
of  its  kind  in  existence,  and  even  to  the  physician  or 
medical  student  who  can  spare  five  dollars  to  pur- 
chase it,  we  feel  sure  the  practical  information  he 
will  obtain  will  more  than  compensate  him  for  the 
outlay. — Caruida  Med.  Journal,  Nov.  1S64. 

The  medical  student  and  the  practising  physician 
will  find  the  volume  of  inestimable  worth  for  study 
and  reference. — San  Francisco  Med.  Press,  July, 

\mv. 

When  we  say  that  this  book  is  in  some  respects 
the  best  jvhich  has  been  published  on  the  subject  in 
the  English  language  for  a  great  many  years,  we  do 
not  wi.sh  it  to  be  understood  as  very  extravagant 
praise.  Iu  truth,  it  is  not  so  much  the  best  as  the 
only  book. —  The  London  Chemical  New/i. 

An  attempt  to  furnish  anything  like  an  analysis  of 
Parrish's  very  valuable  aud  elaborate  Treali.ie  on 
Prortic'd  Phrirmacy  would  require  more  space  than 
we  have  at  our  disposal.  This,  however,  is  not  ho 
much  a  matter  of  regret,  inasmuch  as  it  would  be 
difficult  to  think  of  any  point,  however  minute  and 
apparently  trivial,  connected  with  the  manipulation 


of  phariuaueutlc  substances  or  appliances  which  has  |  March,  1864. 


not  been  clearly  and  carefully  discussed  in  this  vol- 
ume. Want  of  space  prevents  our  enlarging  further 
on  this  valuable  work,  and  we  must  conclude  by  a 
simple  expression  of  our  hearty  appreciation  of  its 
merits. — Duf/lin  Quarterly  Jour,  of  Medical  Science, 
August,  1864. 

We  have  in  this  able  and  elaborate  work  a  fair  ex- 
position of  pharmaceutical  science  as  it  exists  in  the 
United  States  ;  aud  it  shows  that  our  transatlantic 
friends  have  given  the  subject  most  elaborate  con- 
sideration, and  have  brought  their  art  to  a  degree  of 
perfection  which,  we  believe,  is  scarcely  to  be  sur- 
passed anywhere.  The  book  is,  of  course,  of  more 
direct  value  to  the  medicine  maker  than  to  the  physi- 
cian ;  yet  Mr.  Parkisu  has  not  failed  to  introduc* 
matter  in  which  the  prescriber  is  quite  as  much 
interested  as  the  compounder  of  remedies.  In  cua- 
clusion,  we  can  only  express  our  high  opinion  of  tl.e 
value  of  this  work  as  a  guide  lo  the  pharmaceutist, 
and  in  many  respects  to  the  phys-ician.  not  only  in 
America,  but  in  other  part:*  of  the  world. — British 
Med.  Journal,  Nov.  12th,  1861. 

The  former  editions  have  been  suflUciently  long 
before  the  medical  public  to  render  the  merits  of  the 
work  well  known.  It  is  certainly  one  of  the  mosl 
complete  aud  valuable  works  on  practical  pharmacy 
to  which  the  student,  thf  practitioner,  or  the  apothe- 
cary can  have  access. — Chicago  Medical  hxaminer. 


jyUNGLTSON  [RODLEY],  M.D., 

-^  Profexsor  of  InMitute.s  of  Medicine  in  Jeffenioyi  Medical  ColUge,  Philadelphia, 

GENERAL  THEUAPETTICS  ANT)  MATEIUA  MEDICA;  adapted 

for  a  Medical  Text-Book.     With  Inde.xe.s  of  Reineilies  and  of  Diseases  and  their  Remedies. 
Sixth  edition,  revised  and  improved.    With  one  hundred  and  ninety-three  illustrations.    In 
two  large  and  handsomely  printed  octavo  vols,  of  about  1100  pages,  extra  cloth.     $6  50. 
TtT  THE  SAME  AUTHOR.  

NEW  REMEDIES,  WITH  FORMUL.T:  FOR  THEIR  PREPARA- 
TION AND  ADMINISTRATION.  Seventh  e<lition,  with  extensive  additions.  In  one 
very  Large  octavo  volume  of  77U  pages,  extra  cloth.     $4  00. 


12       Henry  C.  Lea's  Publications — {Mat.  Med.  and  Therapeutics). 
ariLLE  {ALFRED).  M.D., 

A3  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Third  edition,  revised  and  enlarged.     In  two  large  and  handsome  octavo  volumes  of  about 
1700  pages,  extra  cloth,  $10  ;  leather,  $12.     {Naw  Ready.) 
That  two  large  editions  of  a  work  of  such  magnitude  should  be  exhnusted  in  a  few  yenrs,  is 
snfficient  evidence  that  it  has  supplied  a  want  generally  felt  by  the  profession,  and  the  unani- 
mous commendation  bestowed  upon  it  by  the  medical  press,  abroad  as  well  as  at  home,  shows 
that  the  author  has  successfully  accomplished  his  object  in  presenting  to  the  profession  a  system- 
atic treatise  suited  to  the  wants  of  the  practising  physician,  and   unincumbered  with  details 
interesting  only  to  the  naturalist  or  the  dealer.     Notwithstanding  its  enlargement,  the  present 
edition  has  been  kept  at  the  former  very  moderate  price. 

From  the  Preface  to  the  Third  Edition. 
Although  the  second  edition  of  this  work  had  for  many  months  been  out  of  print,  the  author 
preferred  to  delay  a  new  issue  of  it,  rather  than  omit  anything  which  appeared  to  be  substantially 
valuable  among  the  recent  advances  of  the  science  nnd  art  of  Therapeutics.     The  subjects  now 
treated  of  for  the  first  time,  are  :  Chromic  Acid;  Permanganate  op  Potassa;  The  Sulphites 
OF  Soda,  etc.  ;  Carbolic  Acid;  Nitrous  Oxide;  Rhigolejje  :  and  Calabar  Bean.     The 
article  on  Bromine  has  been  prepared  entirely  anew ;   and  that  on  Electricity  very  materially 
emlarged  by  an  account  of  the  most  recent  improvements  in  electrical  apparatus,  and  in  the  appli- 
cation of  this  agent  to  the  cure  of  disease.     The  additions  which  have  been  mentioned,  with 
much  new  matter  besides,  which  will  be  found  under  the  more  important  titles,  occupy  nearly 
one  hundred  pages. 
April,  1868. 
A  few  notices  of  former  editions  are  subjoined. 

We  have  placed  flr.st  on  the  list  Dr.  Stillfe'8  great  ,  hardly  find  a  work  written  In  a  style  more  clear  and 
work  on  Therapeutics.  When  the  first  edition  of  this  !  simple,  conveying  forcibly  the  facts  tanght,  and  yet 
work  made  its  appearance  nearly  five  years  ago,  we  !  free  from  tnrgidity  and  redundancy.  There  i.s  a  fas- 
expressed  our  high  sense  of  its  value  as  containing  a  |  cination  in  its  pages  that  will  insure  to  it  a  wide  po- 
fuU  and  philosophical  account  of  the  existing  state  [  pularity  and  attentive  pernwal,  and  a  degree  of  use- 
of  Therapeutics.  From  the  opinion  expressed  at  that  fnlness  not  often  attained  through  the  influence  of  a 
time  we  have  nothing  to  retract;  we  have,  on  the  i  t-ingle  work.  The  author  has  mnch  enhanced  the 
contrary,  to  state  that  the  introduction  of  numerous  ,  practical  ntility  of  his  book  by  passing  brieliy  over 
additions  has  rendered  the  work  even  more  complete  i  the  physical,  botanical,  and  commercial   history  of 


than  formerly.  We  can  cordially  recommend  to  those 
of  our  readers  who  are  interested  in  Therapentlos  a 
careful  perusal  of  Dr.  StilU's  work. — Edinburgh  Med. 
Journal^  1S6.5. 


medicines,  and  directing  attention  chiefly  to  their 
physiological  action,  and  their  application  for  the 
amelioration  or  cure  of  disease. — Chicago  Med.  Jour- 
nal, March,  1860. 


.An  admirable  digest  of  our  present  knowledge  of        ,    ^      ^   , ,  , 
Materia  Medica  and  Therapeutics.— ^m.  Joum.  Med.  I  ,    "  has  held  from  Its  appearance  in  1S60,  the  place 
Sciences  July  1860  "  *"  '^cH  deserves,  that  of  the  best  treatise  on  Thera- 

_     „..',,     '  ,       '.,         ,         .V  ».  ,  I  pputics   in   the   English    language.     A   con-iiderable 

Dr.  Stillfe  8  splendid  work  on  therapeutics  and  ma-    amount  of  new  matter  has  been  a.lded  to  tliia  edition 


teria  medica. — London  Med.  Times,  April  8,  186.5, 

We  think  this  work  will  do  much  to  obviate  the 
reluctance  to  a  thorough  investigation  of  this  branch 
of  scientific  study,  for  in  the  whole  range  of  medical 
literature  treasured  In  the  English  tongue,  we  shall 


without  increasing  its  bulk,  and  its  general  appear- 
ance Is  all  that  could  be  desired  of  u  work  which 
should  find  a  place  in  the  hand  library  of  every  stu- 
dent and  physician. — Boston  Med.  and  Surg.  Jour- 
nal, Deo.  Id,  18(>i. 


QRIFFITH  {ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,   Containing  the  Methods  of  Pre- 

paring  and  Administering  OfBcinal  and  other  Medicines.     The  whole  adapted  to  Physicians 
and  Pharmaceutists.     Second  edition,   thoroughly  revised,  with  numerous  additions,  by 
Robert  P.  Thomas,  M.D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of 
Pharmacy.     In  one  large  and   handsome   octavo  volume  of  650  pages,  double-dolumns. 
Extra  cloth,  $4  00;  leather,  $5  00. 
In  this  volume,  the  Formulary  proper  occupies  over  400  double-column  pages,  and  contains 
about  5000  formulas,  among  which,  besides  those  strictly  medical,  will  be  found  numerous  valuable 
receipts  for  the  preparation  of  essences,  perfumes,  inks,  soaps,  varnishes,  Ac.  <tc.     In  addition  to 
this,  the  work  contains  a  vast  amount  of  information  indispensable  for  daily  reference  by  the  prac- 
tising physician  and  apothecary,  embracing  Tables  of  Weights  and  Measures,  Specific  Gravity, 
Temperature  for  Pharmaceutical  Operations,  Hydrometrical  Equivalents,  Specific  Gravities  of  some 
of  the  Preparations  of  the  Pharmacopoeias,  Relation  between  different  Thermometrical  Scales, 
Explanation  of  Abbreviations  used  in  Formulae,  Vocabulary  of  Words  used  in  Prescriptions,  Ob- 
servations on  the  Management  of  the  Sick  Room,  Doses  of  Medicines,  Rules  for  the  Administration 
of  Medicines,  Management  of  Convalescence  and  Relapses,  Dietetic  Preparations  not  included  in 
the  Formulary,  List  of  Incompatibles,  Posological  Table,  Table  of  Pharmaceutical  Names  which 
differ  in  the  Pharmacopoeias,  Officinal  Preparations  and  Directions,  and  Poisons. 

Three  complete  and  extended  Indexes  render  the  work  especially  adapted  for  immediate  consul- 
tation. One,  of  Diseases  and  their  Remedies,  presents  under  the  head  of  each  disease  the 
remedial  agents  which  have  been  usefully  exhibited  in  it,  with  reference  to  the  formulfe  containing 
them — while  another  of  Pharmaceutical  and  Botanical  Names,  and  a  very  thorough  Ge.veral 
Index  afford  the  means  of  obtaining  at  once  any  information  desired.  The  Formulary  itself  is 
arranged  alphabetically,  under  the  heads  of  the  leading  constituents  of  the  prescriptions. 

This  is  one  of  the  most  useful  books  for  the  prac-        We  know  of  none  in  our  language,  or  any  other,  so 
Msing  physician  which  has  been  issued  from  the  press    comprehensive  in  its  details. — London  Lancet. 
of  late  years,  containing  a  vast  variety  of  formulas        ^         ,,,  ,  ,  ^  ,       ,^,     ..    ,  .     „_„ 

for  the  safe  and  convenient  administration  of  medi-     ,   0°«  of  the  mos   complete  works  of  the  kind  m  any 
oines,  all  arranged  upon  scientific  and  rational  prin-    language.— £di«t«rg/.  Mtd.  Journal. 
ciples,  with   the  quantities  stated   in  full,  without        We  are  not  cognizant  of  the  existence  of  a  paraUei 
signs  or  abbreviations. — Memphis  Med.  Recorder.  work. — London  Med.  Gazette. 


Henry  C.  Lea's  Publications — (3IaL  Med.  and  Therapeutics).      13 


pEREIRA  {JONATHAN),  M.D.,  F.R.S.  and  L.S. 

MATERIA    MEDICA   AND  THERAPEUTICS;   being  an  Abridtr- 

ment  of  the  late  Dr.  Pereira's  Elements  of  Materia  Merlica,  arranged  in  conformity  with 
the  British  Pharmacopoeia,  and  adapted  to  the  use  of  Medical  Practitioners,  Chemists  and 
Druggists,  Medical  and  Pharmaceutical  Students,  <fec.  By  F.  J.  Farre,  M.D.,  Senior 
Physician  to  St.  Bartholomew's  Hospital,  and  London  Editor  of  the  British  Pharmacopoeia; 
assisted  by  Robert  Bentley,  M.R.C.S.,  Professor  of  Materia  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain;  and  by  Robert  Warington,  F.R.S. ,  Chemical 
Operator  to  the  Society  of  Ajtothecaries.  With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood,  M.D.,  Professor  of  Botany  in  the 
University  of  Pennsylvania.  In  cue  large  and  handsome  octavo  volume  of  1040  closely 
printed  pages,  with  236  illustrations,  extra  cloth,  $7  00;  leather,  raised  bands,  $8  00. 
{Just  Issued.) 


The  task  of  the  American  editor  has  evidently  been 
ao  sinecure,  for  not  only  hn.s  he  given  to  us  all  that 
is  contained  in  the  ahridgment  useful  for  our  pur- 
poses, but  by  a  careful  and  judicious  omhodiment  of 
over  a  hundred  new  remedies  has  increased  the  size 
of  the  former  work  fully  one-third,  besides  adding 
many  new  illustrations,  some  of  which  are  original. 
We  unhesitatingly  say  that  by  so  doing  he  has  pro- 
portionately increased  the  value,  not  only  of  the  con- 
densed edition,  but  lias  extended  the  applicability  of 
the  great  original,  and  has  placed  his  medical  coun- 
trymen under  lasting  obligations  to  him.  The  Ame- 
rican physician  now  has  all  that  is  needed  in  the 
shape  of  a  complete  treatise  on  materia  medica,  and 
the  medical  student  has  a  text-book  which,  for  prac- 
tical utility  and  intrinsic  worth,  stands  unparalleled. 
Although  of  considerable  size,  it  is  none  too  large  for 
the  purposes  for  which  it  hasbeen  intended,  and  every 
medical  man  should,  in  justice  to  himself,  spare  a 
place  for  it  upon  his  book-shelf,  resting  assured  that 
the  more  he  consults  it  the  better  he  will  be  satisfied 
of/its  excellence.*— .A^.  Y.  Med.  Record,  Nov.  15,  1866. 

It  will  fill  a  place  which  no  other  work  can  occupy 
In  the  library  of  the  physician,  student,  and  apothe- 
cary.— Boston  Med.and  Sur</.  Journal,  Nov.  8,  18()6. 

Of  the  many  works  on  Materia  Medica  which  have 
appeared  since  the  issuing  of  the  British  Pharmaco- 


poeia, none  will  be  more  acceptable  to  the  student 
and  practitioner  than  the  present.  Pereira's  Materia 
Medica  had  long  ago  asserted  for  itself  the  position  of 
being  the  most  complete  work  on  the  subject  in  the 
English  language.  But  its  very  completeness  stood 
in  the  way  of  its  success.  Except  in  the  way  of  refer- 
ence, or  to  those  who  made  a  special  study  of  Materia 
Medica,  Dr.  Pereira's  work  was  too  full,  and  its  pe- 
rusal required  an  amount  of  time  which  few  had  at 
their  disposal.  Dr.  Farre  has  very  judiciously  availed 
himself  of  the  opportunity  of  the  publication  of  tho 
new  Pliarmacopceia,  by  bringing  out  an  abridged  edi- 
tion of  the  great  work.  This  edition  of  Pereira  is  by 
no  means  a  mere  abridged  re-issue,  but  contains  ma- 
ny improvements,  both  in  the  descriptive  and  thera- 
peutical departments.  We  can  recommend  it  as  a 
very  excellent  aud  reliable  text-book. — Edinburgh 
Med  Jouriuil,  February,  1866. 

The  reader  cannot  fail  to  be  impressed,  at  a  glance, 
with  the  exceeding  value  of  this  work  as  a  cornpeud 
of  nearly  all  useful  knowledge  on  the  materia  medica. 
We  are  greatly  indebted  to  Professor  Wood  for  his 
adaptation  of  it  U>  our  meridian.  Without  his  emen- 
dations aud  additions  it  would  lose  much  of  its  valne 
to  the  American  sludpnt.  With  them  it  is  an  Ameri- 
can book.  — PaoiAc  Medical  and  Surgical  Journal 
December,  1866.  ' 


TJLLIS  [BENJAMIN],  M.D. 


THE  MEDICAL  FORMULARY:  being  a  Collection  of  Prescriptions 

derived  from  the  writings  and  practice  of  mnny  of  the  most  eminent  physicians  of  America 
and  Europe.  Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Twelfth  edi- 
tion, carefully  revised  and  much  extended  by  Albert  H.  Smith,  M.  D.,  Professor  of  Materia 
Medica  in  the  Philadelphia  College  of  Pharmacy.     In  one  volume  8to.     (Nearly  Ready.) 

frequently  noticed  in  this  Journal  as  the  successive 
editions  appeared,  that  it  is  sufHcient,  on  the  present 
occasion,  to  state  that  the  editor  has  introduced  intu 
the  eleventh  edition  a  largo  amount  of  new  matter, 
derived  from  the  current  medical  and  pharmaceutical 
works,  as  well  as  a  number  of  valuable  prescrii)tions 
furnished  from  private  sources.  A  very  comprehen- 
sive and  extremely  u.seful  index  has  also  been  sup- 
plied, which  facilitates  reference  to  the  particular 
article  the  prescriber  may  wish  to  administer;  aiiJ 
t)ie  language  of  the  Formulary  has  been  made  to  coi- 
respond  with  the  nomenclature  of  tho  new  nation,tl 
Pharmacopoeia.— >lm.  Jour.  Med.  Sciences,  Jan.  lSu4. 


We  endorse  the  favorable  opinion  which  the  book 
has  so  long  established  for  itself,  and  take  this  occa- 
sion to  commend  it  to  onr  readers  as  one  of  the  con- 
venient handbooks  of  the  office  and  library. — Cin- 
einnnti  Lancet,  Feb.  186t. 

The  work  has  long  been  before  the  profession,  and 
Its  merits  are  well  known.  The  present  edition  con- 
tains many  valuable  additions,  and  will  be  found  to 
be  an  exceedingly  convenient  and  useful  volume  for 
reference  by  the  medical  practitioner.  —  Chicago 
Medical  'Examiner,  March,  1864. 

The  work  is  now  so  well  known,  and  has  been  so 


c 


ARSON  (JOSEPH),  M.D., 

Profe.inor  of  Materia  Midira.  and  Pharmacy  in  the  Univer-iity  of  PeuTUiylvania,  An. 

SYNOPSIS  OF  THE   COURSE   OP   LECTURES   ON   MATERIA 

MEDICA  AND  PHARMACY,  delivered  in  the  "University  of  Pennsylvania.  With  throe 
Lectures  on  the  Modus  Operandi  of  Medicines.  Fourth  and  revised  edition,  extra  cloth 
$3  00.     (Now  Ready.)  


ROYLB'S    MATERIA    MEDICA    AND    THEHAPED- 

ticn;  including  the  Preparations  of  the  Pharma- 
copoeias of  London,  Ediubnrgh,  Dublin,  and  of  the 
United  States.  With  many  new  medicines.  Edited 
by  .TosEPH  Carson,  M.D.  With  ninety-eight  illus- 
trations. In  one  large  octavo  volume  of  about  700 
pages,  extra  cloth.  $!  00. 
CHRISTISON'S  DISPENSATORY;  or.  Comhbntaut 
on  the  Pharmacopojias  of  Great  Britain  and  the 
United  States.  With  copious  additions,  and  21.3 
large  wood-engravings.  By  R.  Eoi-K.-iPKi.DfiuiKFiTH, 
M.I).  In  one  very  handsome  octavo  volume  of  over 
1000  pages,  extra  cloth,     lilt  00. 


CARPENTER'S  PUIZE  E.S.«AY  ON  THE  USE  OF 
Ai.ronoi.in  Liqimrs  i.v  IIkai.tii  and  Disease.  Ni-w 
edition,  with  a  Prefuce  by  I).  "F.  Conuib,  JI.D..  mid 
explanations  of  scienllflc  words.  In  one  neat  l'2ma. 
volume,  pp.  178,  extra  cloth.     60  cents. 

De  JONOH  on  the  three  kinds  OF  COD-LIVER 
Oil,  with  their  Chemical  and  Therapeutic  Pro- 
perties.    1  vol.  12mo.,  cloth.     7.^  cents. 

MAYNE'S  DISPENSATORY  AND  THKRAPEtTTICAL 
RKMKMnKANCKR.  With  every  I'ractical  Formula 
contniued   in    the   three    British    PharmacopmiaH. 

I  Edited,  with  the  addition  of  the  Formula!  of  the 
U.  S.  Pharmacopojia,  by  R.  E.  Orifkitu,  M.  D.     la 

I      one  12mo.  volume,  300  pp.,  extra  cloth.     TCi  ceuli*. 


14 


Henry  C.  Lea's  Publications — (Pathology). 


fyROSS  {SAMUEL  D.),  M.  D., 

^^  Prnfesxor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

ELEMENTS    OF    PATHOLOGICAL   ANATOMY.     Third    edition, 

thoroughly  revised  and  greatly  improved.     In  one  large  and  very  handjome  octiivo  volaino 
of  nearly  800  pages,  with  about  three  hundred  and  fifty  beautiful  illustrations,  of  which  a 
large  number  are  from  original  drawings  ;   extra,  cloth.     $4  00. 
The  very  beautiful  execution  of  this  valuable  work,  and  the  exceedingly  low  price  at  which  it 
is  offered,  should  command  for  it  a  place  in  the  library  of  every  practitioner. 


To  the  student  of  medicine  we  would  say  tliat  we 
kmiw  of  no  work  which  we  can  more  heartily  com- 
mand than  Gross's  Pathological  A^naXoiay.— Southern 
yfed  and  Surg.  Journal. 

The  volume  commends  itself  to  the  medical  student ; 
it  will  repay  a  careful  perasal,  and  should  be  upou 


thebook-shelf  of  every  American  physician. — Charles- 
tim  Med.  Journal. 

It  contains  mnch  new  matter,  and  brings  down  our 
knowledge  of  pathology  to  the  latest  period. — Londun 
Lancet. 


J 


ONES  [G.  HANDFIELD),  F.R.S.,  and  SIEVEKING  [ED.  K),  M.D., 

Aissivtant  Physicians  and  Lecturers  in  St.  Mary's  Hospital. 

A  MANUAL  OF   PATHOLOGICAL  ANATOMY.     First  American 

edition,  revised.     With  three  hundred  and  ninety-seven  handsome  wood  engravings.     In 
one  large  and  beautifully  printed  octavo  volume  of  nearly  760  pages,  extra  cloth,  $3  50. 

and  the  most  recent  invo.stigations  presented  in  suift- 
cient  detail  for  the  student  of  pathology.  We  cannot 
at  this  time  undertake  a  formal  analysis  of  this  trea- 
tise, as  it  would  involve  a  separate  snd  lengthy 
considoralion  of  nejirly  every  subject  discussed  ;  nor 
wonld  such  analysis  be  advantageons  to  (he  medical 
reader.  The  work  is  of  snch  a  character  that  every 
physician  ought  to  obtain  it,  both  for  refereneo  and 
study. — N.  ¥.  Joumnl  of  Medicine. 

Its  importance  to  the  physician  cannot  be  too  highly 
estimated,  and  we  wonld  recommend  our  readoi-s  to 
add  it  to  (heir  library  as  soon  a8 tf ey  couveQiently 


Oar  limited  space  alone  restrains  us  from  noticing 
more  at  length  the  various  subjects  treated  of  in 
this  interesting  work ;  presenting,  as  it  does,  an  excel- 
lent summary  of  the  existing  state  of  knowledge  in 
relation  to  pathological  anatomy,  we  cannot  too 
sti'ougly  urge  upon  the  student  the  necessity  of  a  tho- 
rough acquaintance  with  its  contents. — Medical  Ex- 
aminer. 

We  have  long  had  need  of  a  hand-book  of  patholo- 
gical anatomy  which  should  thoroughly  reflect  the 
present  state  of  that  science.  In  the  troitise  bef>ire 
ns  this  desideratum  is  bnpplied.    Within  the  limits  of 

a  moderate  octavo,  we  have  the  outlines  of  this  great  I  can. — MimireM  Med.  Chronicle. 
department  of  medical  Bcieuce  accurately  deQued,  | 


T>OKITANSKY  {CARL),  M.J)., 

Curator  of  the  Imperial  Pathological  MvJteum,  and  Profe.isor  at  the.  ITntversity  of  Vienna. 


A   MANUAL   OF   PATHOLOGICAL   ANATOMY. 

W.  E.  SwAiNE,  Edward  Sievekivo,  C.  H.  Mooke,  and  Q.  E.  Day. 
bound  in  two,  of  about  12U0  pages,  extra  cloth.     $7  50. 


Translated  by 

Four  volnmeB  octavo. 


GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOOV. 
Translated,  with  Notes  and  Additions,  by  JasEPU 
Letdy,  M  I).  lu  one  volnrae,  very  large  imperial 
qnarto,  with  320  copper-plate  figures,  plain  and 
colored,  extra  cloth.     $100. 


SIMON'S  GENERAL  P.\THOLOGY,  as  conducive  to 
the  Establishment  of  Katicmal  Principles  for  the 
I'revtMition  anil  Cure  of  l)i-pase.  In  one  octavo 
Tolumo  of  212  pages,  extra  cloth.     91  25. 


TJ/'ILLIAMS  {CHARLES  J.  B.),  M.D., 

Profejisfir  of  Clinical  Medicine  in  University  College,  London. 

PRINCIPLES  OF  MEDICINE.     An  Elementary  View  of  the  Causes, 

Nature,  Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics, 

or  the  preservation  of  health.     A  new  American,  from  the  third  and  revised  London  edition. 

In  one  octavo  volume  of  about  500  pages,  extra  cloth.     $3  50. 

The  unequivocal  favor  with  which  this  work  has  I      A  text-book  to  which  no  other  in  our  language  1« 

been  received  by  the  profession,  both  in  Europe  and  |  comparable. — Charleston  Med.  Journal. 

America,  is  one  among  the  many  gratifying  evidences  i      jhe  lengthened  analysis  we  have  given  of  Dr  Wil- 

which  miijht  be  adduced  as  going  to  show  that  there  |  liams's  Principles  of  Medicine  will,  we  trust,  clearly 

isasteadyprogrjesMakingpUce^in  thejci^en^^^^^  !  prove  to  our  readers  his  perfect  competency  for  thfe 

^^       ,.„„      t^jsk   he  has  undertaken — that   of  in>part!ng  to   the 


as  in  the  art  of  medicine. — St.  Louis  Med.  and  Surg 
Journfd. 

No  work  has  ever  achieved  or  maintained  a  more 
deserved  reputation. —  Virginia  Med.  and  Stirg. 
Journal. 


student,  as  well  as  to  tha  more  experieucnl  practi- 
tioner, a  knowledge  of  those  general  principles  of 
pathology  on  which  alone  a  orrect  practice  can  b« 
founded.      The  absolute    necessity   of  s8cli    a    w^irft 


One  of  the  best  works  on  the  subject  of  which  Jt  I  w"*'  »>»  evident  to  all  who  pretend  to  more  than 
treats  in  our  laugua-'e  1  """*  empiricism.     We  must  conclude  by  again  ex- 

,  ,      ,,        V     v  1.  J  I  pressing  our  high  sense  of  the  immense  benefit  which 

It  has  already  commended  itself  to  the  high  regard  i  d^  Williams  has  conferrM  on  medicine  by  the  pnb- 
of  the  profession;  and  we  may  well  .say  that  we  |  Hcation  of  this  work.  We  are  certain  that  in  tlra 
know  of  no  single  volume  that  will  afford  the  source  i  present  state  of  our  knowledge  his  Principles  of  Medi- 
of  so  thorough  a  drilling  in  the  principles  of  practice  I  cj„g  pQ„|j   ^^j   possibly   be  .snrpas.sed.     While   we 


this.  Students  and  practitioners  should  make 
themselves  intimately  familiar  with  its  teachings — 
they  will  find  their  labor  and  study  most  amply 
repaid. — Cincinnati  Med.  Observer. 

There  is  no  work  in  medical  literature  which  can 
fill  the  place  of  thi.s  one.  It  is  the  Primer  of  the 
young  practitioner,  the  Koran  of  the  scientific  one. — 
Stethoscope. 


regret  the  loss  which  many  of  the  rising  generation 
of  practitioners  have  sustained  by  his  resignation  of 
the  Chair  at  University  College,  it  is  comforting  to 
feel  that  his  writings  must  long  continue  to  exert  a 
powerful  influence  on  the  practice  of  that  profession 
for  the  improvement  of  which  he  has  so  assiduously 
and  successfully  labored,  and  in  which  he  holds  so 
distinguished  a  position. — London  Jour,  of  Mbdicim 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


15 


PLINT  {A  USTIN),  M.  D., 

-*■  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  K.  T. 

A   TREATISE    ON    THE    PRINCIPLES    AND    PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Second 
eiHtion,  revised  and  enlaru;e(l.  In  one  large  and  closely  printed  octavo  volume  of  nearly 
]()(I0  pages;  handsome  extra  cloth,  $6  50;  or  strongly  bound  in  leather,  with  laised  baMJs, 
$7  50.    {Just  Issued.) 

From  the  Preface  to  the  Second  Edit-ion. 
Four  months  nfter  the  publication  of  this  treatise,  the  author  was  notified  that  a  cecond  edition 
was  called  for.  The  speedy  exhaustion  of  the  fir.<:t  edition,  unexpected  in  view  of  its  large  size, 
naturally  intensified  the  desire  to  make  the  work  still  more  acceptable  to  practitioners  and 
students  of  Medicine;  and,  notwithstanding  the  brief  period  allowed  for  a  revision,  additions 
have  been  made  which,  it  is  believed,  will  enhance  the  practical  utility  of  the  volume. 

Weai'e  happy  in  heiug  able  once  nuire  to  coininpiid 
this  Work  to  thestudents  and  practitioners  of  medicine 
who  seek  fur  accurate  information  convoyed  in  Ian 


guage  at  once  clear,  precise,  and  expressive. — Amer. 
Journ.  Med.  Sciences,  April,  1S67. 

Dr.  Flint,  who  has  been  known  in  this  eonntry  for 
many  years,  both  as  an  author  and  teacher,  who  has 
discovered  Irutb,  and  pointed  it  out  clearly  and  dis- 
tinctly to  others,  investigated  the  symptoms  and  na- 
tural liistory  of  disease  and  recorded  its  language  and 
facts,  aud  devoted  a  life  of  incessant  study  and 
tlionght  to  the  doubtful  or  obscure  in  his  profession, 
has  at  length,  in  his  ripe  scholarship,  given  this  work 
t<)  the  profession  as  a  crowning  gift.  If  we  have  spoken 
highly  of  its  value  to  the  profession  and  world  ;  if  we 
have  said,  all  considered,  it  is  the  very  best  work 
upon  medical  practice  in  any  language;  if  we  have 
spoken  of  its  excellences  in  detail,  and  given  points 
of  special  value,  we  hive  yet  failed  to  express  in  any 
4egr»e  our  present  estimate  of  its  value  as  a  guide  in 
the  practice  of  medicine.  It  does  not  contain  too  much 
or  too  little ;  it  is  not  positive  where  doubt  should  he 
<}spressed,  or  hesitate  where  truth  is  known.  It  is 
philosophical  and  speculative  whei-e  philosophy  and 
speculation  are  all  that  can  at  present  be  obtained, 
but  nothing  is  admitted  to  the  elevation  of  established 
truth,  without  the  most  thorough  investigation.  It 
Is  truly  remarkable  witb  what  even  hand  this  work 
has  been  written,  and  how  it  all  shows  the  most  care- 
ful thought  and  untiring  study.  We  conclude  that, 
though  it  may  yet  be  susceptible  of  improvement,  it 
still  constitutes  the  very  best  which  human  knowledge 
can  at  present  produce.  "When  knowledge  is  in- 
<yeased,"  the  work  will  doubtless  be  again  revised;  j  ''"'"   .  -mi.  .-.■ 

rr  ,.„„v,!i ,1,   n   „   ,„.,.  !,  .    .1  -  ..   1     ,r  .,...„,;„„    '  to  arijve  at  a  correct  diagnosis.     TJie  practitionxr, 

nioanwhile  we  shall  accept  it  as  tlie  rule  of  practice,    i       i      ,      ■  i      j     i         w      a \    L-      .\ 

-         -  -  -  '^  -   _    .  J  besides  having  such  aids,  has  offered  to  him  the  con- 

clusion which  the  experience  of  the  professor  hag 


ranked  among  heavy  and  common- place  works,  whilfl 
the  unmistakable  way  in  which  Dr  Flint  gives  his 
own  views  is  (juite  refreshing,  and  far  from  common. 
It  is  a  book  of  enormous  research  ;  the  writer  is  evi- 
dently a  man  of  observation  and  large  experience; 
his  views  are  practically  sound  and  theoretically 
moderate,  and  we  have  no  hesitation  in  commending 
his  rniignum  opus-  to  our  readers  — Dublin  Medical 
Press  and  Circular,  May  16,  IS66. 

In  the  plan  of  the  work  and  the  treatment  of  indi- 
vidual subjects  there  is  a  freshness  and  an  originality 
which  make  it  worthy  of  the  study  of  practitioneiH 
as  well  as  students  It  is,  indeed,  an  admirable  book, 
and  highly  creditable  to  American  medicine.  For 
clearness  and  conciseness  in  style,  for  careful  reason- 
ing upon  what  is  known,  for  lucid  distinction  between 
what  we  know  and  what  we  do  not  know,  between 
what  nature  does  in  disease  aud  what  the  physician 
can  do  aud  should,  for  richness  in  good  clinical  ob- 
servation, for  independence  of  statement  and  opinion 
on  great  points  of  practice,  and  for  geneial  sagacity 
and  good  judgment,  the  work  is  most  meritorious. 
It  is  singularly  rich  in  good  qualities,  and  free  from 
faults. — London  Lxincet,  June  2.3,  1866. 

In  following  out  such  a  plan  Dr.  Flint  has  sac- 
ceeded  most  admirably,  and  gives  to  his  readers  a 
work  that  is  not  only  very  readable,  interesting, 
and  concise,  but  in  every  respect  calculated  to  meet 
the  requirements  of  professional  men  of  every  clasH. 
The  student  has  presented  to  him,  in  the  plainest 
possible  manner,  the  symptoms  of  disease,  the  prin- 
cijiles  which  sliould  guide  him  in  its  treatment,  and 
the  difficulties  which  have  to  l>e  surmounted  in  order 


^Buffalo  Med.  and  Surg.  Journal,  Feb.  1867. 

He  may  justly  feel  proud  of  the  high  honor  con- 
fwred  on  him  by  the  demand  for  a  second  edition  of 
bis  work  in  fonr  months  after  the  issue  of  the  first. 
Jfo  Amerit-an  practitioner  can  alford  to  do  withovit 
Flint's  Practice. — Pacific  Mexi.  aud  Surg.  Journal, 
Feb.  1867. 

Dr.  Flint's  book  is  the  only  one  on  the  practice  of 
medicine  that  can  benefit  the  young  practitioner. — 
Nasfiville  Med.  Journal,  Aug.  1S66. 

We  consider  the  book,  in  all  its  es.sentials,  as  the 


enabled  liim  to  arrive  at  in  reference  to  the  relative 
merits  of  different  therapeutical  agents,  and  diffeiiMit 
methods  of  treatment.  This  new  work  will  add  not 
a  little  to  the  well-earned  reputation  of  Prof.  Flint  an 
a  medical  teacher. — N.  Y.  Med.  Record,  April  2,  1806. 

We  take  pleasure  in  recommending  to  the  profession 
this  valuable  and  practical  work  on  the  practice  of 
medicine,  more  particularly  as  we  have  had  oppor- 
tunities of  appreciating  from  personal  observatioa 
the  author's  preeminent  merit  as  a  clinical  observer. 


best  adapted  to  the  student  of  any  of  our  numerous  j  This  work  is  undoubtedly  one  of  great  merit,  iind  we 

text-books  on  tins  subject. —iV.r  Jlf«i.  ./ourn.,  Jan.'67.     f,,el  confident  that  it  will  have  an  extensive  circula- 

Its  terse  couciseness  fully  redeems  it  from  being    WnA.—  Tlut  N.  0.  Med.  and  Surg.  Journal,  Sept.  IbtW. 


TiUNGLISON,  FORBES,  TWEED  IE,  AND  COXOLLV. 

THE  CYCLOPAEDIA   OF    PRACTICAL  MEDICINE:    comprising 

Treatise*"  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  Therajwutici", 
Disea.ses  of  Women  and  Children,  Meilical  .lurisprmlcnce,  Ac.  .tc.  In  four  large  super-rnyal 
octavo  volumes,  o  j;V254  double-columned  pages,  strongly  and  hiindsomely  bound  in  Icaihur, 
$15^  extra  cloth,  $11. 
*jir*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed 
by  sixty-eight  distinguished  physicians. 

the  day.     As  a  work  of  reference  It  Is  invalnahle. — 
Western  journal  of  Medicine  and  Surgtry. 

It  has  beon  to  us,  both  as  Iparuer  and  teacher,  a 
work  for  ready  aud  frequent  reffrence,  one  in  which 
modern  English  medicine  is  exhibited  In  the  most  ad- 
vantageous light. — Medical  E.raminer. 


The  most  complete  work  on  practical  medicine 
extant,  or  at  least  in  our  language. — Buffalo  Medical 
atid  Surgical  Journal. 

For  reference,  it  is  above  all  price  to  every  practi- 
tioner.—  Western  Lancet. 

One  of  the  most  valuable  medical  publications  of 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MKDICI.VE.  With  Additions  by  U.  F.  CoKDlE, 
JI.  I).     1  vol.  Svo.,  pp.  COO,  cloth.     *2  30. 


HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. From  the  third  aud  enlarged  English  edi- 
tion. In  one  handsome  octavo  volume  of  about 
600  pages,  extra  cluth.    $3  iO. 


16 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


TTARTSHORNE  {HENRY),  M.D., 

mJL  Professor  of  Hygiene  in  the  Univerxity  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 
CINE.    A  handy-book  for  Students  and  Practitioners.     In  one  handsome  roynl  ]2ino. 
volume  of  about  350  pages,  clearly  printed  on  small  type,  cloth,  $2  38;  half  bound,  $2  63. 
(Just  Issued. ) 
The  very  cordial  reception  with  which  this  work  has  met  show?  that  the  author  has  fully  suc- 
ceeded in  his  attempt  to  condense  within  a  convenient  compass  the  essential  points  of  scientific 
and  practical  medicine,  so  as  to  meet  the  wants  not  only  of  the  student,  but  also  of  the  practi- 
tioner who  desires  to  acquaint  himself  with  the  results  of  recent  advances  in  medical  science. 

Dearly  than  any  similar  manual  lately  before  us  the 
.standard   at  which  all  such  books   should  aim  —  of 


As  a  strikingly  terse,  full,  and  comprehensive  em- 
bodiment in  a  condensed  form  of  the  essentials  in 
medical  science  and  art,  we  hazard  nothing  in  saying 
that  it  is  incomparably  in  advance  of  any  work  of  the 
kind  of  the  past,  and  will  stand  long  in  the  future 
without  a  rival.  A  mere  glance  will,  we  think,  im- 
press others  with  the  correctness  of  our  estimate.  If  or 
do  we  believe  there  will  be  found  many  who,  after 
the  most  cursory  examination,  will  fail  to  possess  it. 
How  one  could  be  able  to  crowd  so  much  that  is  valu- 
able, especially  to  the  student  and  young  practitioner, 
within  the  limits  of  so  small  a  book,  and  yet  embrace 
and  present  all  that  is  important  in  a  well-arranged, 
clear  form,  convenient,  satisfactory  for  reference,  with 
80  full  a  table  of  contents,  and  extended  general  index, 
with  nearly  three  hundred  formulas  and  recipes,  is  a 
marvel. —  WesteT^  Jonrnal  of  Medicine,  Aug.  1867. 

The  little  book  before  us  has  this  quality,  and  we 
ean  therefore  say  that  all  students  will  find  it  an  in- 
valuable guide  in  their  pursuit  of  clinical  medicine. 
Dr.  Hartshorne  speaks  of  it  as  "an  unambitious  effort 
to  make  useful  the  experience  of  twenty  years  of  pri- 
vate and  hospital  medical  practice,  with  its  attendant 
study  and  reflection."  That  the  effort  will  prove  suc- 
cessful we  have  no  doubt,  and  in  hi.s  study,  and  at 


teaching  much,  and  suggesting  more.  To  tlie  student 
we  can  heartily  recommend  the  work  of  onr  transat- 
lantic colleague,  and  the  busy  practitioner,  we  are 
sure,  will  find  in  it  the  means  of  solving  many  a 
doubt,  and  will  rise  from  the  perusal  of  its  pages, 
having  gained  clearer  views  to  guide  him  in  his  daily 
struggle  with  disease. — Dub.  Med.  Preso,  Oct.  2,  18(i7. 
Pocket  handbooks  of  medicine  are  not  desirable, 
even  when  they  are  as  carefully  and  elaborately  com- 
piled as  this,  the  latest,  most  complete,  and  most  ac- 
curate which  we  have  seen. — British  Med.  Journal, 
Sept.  21,  1S67. 

This  work  of  Dr.  Hartshorne  must  not  be  confound- 
ed with  the  medical  manuals  so  generally  to  be  found 
in  the  hands  of  students,  serving  them  at  best  but  as 
blind  guides,  better  adapted  to  lead  them  astray  than 
to  any  useful  and  reliable  knowledge.  The  work  be- 
fore us  presents  a  careful  synopsi-s  of  the  essential 
elements  of  the  theory  of  diseased  action,  its  causes, 
phenomena,  and  results,  and  of  the  art  of  healing,  aa 
recognized  by  the  most  authoritative  of  our  profes- 
sional writers  and  teachers.  A  very  careful  and  can- 
did examination  of  the  volume  has  conTinced  us  that 
the  bedside,  the  student  will  find  Dr  Hartshorne  a  ]  it  will  be  generally  recognized  as  one  of  the  best  mau- 
■afe  and  accomplished  companion.  We  speak  thus  '  uals  for  the  use  of  the  student  that  has  yet  appeared, 
highly  of  the  volume,  because  it  approaches  more  I  — American  Journal  Med.  Sciences,  Oct.  1867. 


'U/'ATSON  [THOMAS),  M.  D.,  ^c. 

LECTURES     ON     THE     PRINCIPLES    AND    PRACTICE    OP 

PHYSIC.     Delivered  at  Kings  College,  London.     A  new  American,  from  the  last  revised 
and  enlarged  English  edition,  with  Additions,  by  D.  Francis  Condie,  M.  D. ,  author  of 
"A  Practical  Treatise  on  the  Diseases  of  Children,"  Ac.      With  one  hundred  and  eighty- 
five  illustrations  on  wood.     In  one  very  large  and  handsome  volume,  imperial  octavo,  of 
over   1200  closely  printed  pages  in  small  type;    extra  cloth,  $6  50;  strongly  bound   in 
leather,  with  raised  bands,  $7  50. 
Believing  this  to  be  a  work  which  should  lie  on  the  table  of  every  physician,  and  be  in  the  hands 
of  every  student,  every  effort  has  been  made  to  condense  the  vast  amount  of  matter  which  it  con- 
tains within  a  convenient  compass,  and  at  a  very  reasonable  price,  to  place  it  within  reach  of  all. 
In   its  present  enlarged  form,  the  work  contains  the  matter  of  at  least  three  ordinary  octavos, 
rendering  it  one  of  the  cheapest  works  now  offered  to  the  American  profession,  while  its  mechani- 
cal execution  makes  it  an  exceedingly  attractive  volume. 


DICKSON'S  ELEMENTS  OF  MEDICINE;  a  Compen- 
dious View  of  Pathology  and  Therapeutics,  or  the 
History  and  Treatment  of  Diseases.  Second  edi- 
tion, revised.  1  vol.  8vo.  of  750  pages,  extra  cloth. 
$i  00. 

"WHAT  TO  OBSERVE  ATTHE  BEDSIDE  AND  AFTER 
De.\th  in  Medical  C.\ses.  Pnblishi'd  under  the 
authority  of  the  London  Society  for  Medical  Obser- 


vation. From  the  second  London  edition.  I  vol. 
royal  12rao.,  extra  cloth.  $1  00. 
LAYCOCK'S  LECTPRES  ON  THE  PRINCIPLES 
ANn  Methods  op  Medical  Observation  and  Rd- 
SEARCH.  For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  l2mo. 
volume,  extra  cloth.    )ll  00. 


jyARCLAY  [A.  W.),  M.  D. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS;  being  an  Analysis  of  the 

Signs  and  Symptoms  of  Disease.     Third  American  from  the  second  and  revised  London 
edition.     In  one  neat  octavo  volume  of  451  pages,  extra  cloth.     $3  50. 


A   work   of   immense   practical    utility. — London 
Med.  Times  and  Gazette. 


The  book  should  be  in  the  hands  of  every  practical 
man. — DiMin  Med.  Press. 


JPULLER  [HENRY  WILLIAM),  M.  D., 

-^  Physician  to  St.  Oeorge's  Hospital,  London. 

ON  DISEASES  OF  THE   LUNGS   AND   AIR-PASSAGES.     Their 

Pathology,  Physical  Diagnosis,  Symptoms,  3rd  Treatment.  From  the  second  and  revised 
English  edition.  In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $3  50. 
(JSow  Ready.) 

Dr.  Fuller's  work  on  diseases  of  the  chest  was  so  |  accordingly  we  have  what  might  be  with  perfect  jns- 
favorably  received,  that  to  many  who  did  not  know  tice  styled  an  entirely  new  work  from  his  pen,  the 
the  extent  of  his  engagements,  It  was  a  matter  of  won-  |  portion  of  the  work  treating  of  the  heart  and  great 
der  that  it  .should  be  allowed  to  remain  three  years  I  vessels  being  excluded.  Nevertheless,  this  volume  is 
©at  of  print.  Determined,  however,  to  improve  it,  of  almost  equal  .size  with  the  first. — London  Medical 
Dr.  Fuller  would  not  consent  to  a  mere  reprint,  and  j  Times  and  Gazette,  July  2C,  1867. 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


17 


JpLINT  {A  USTIN),  M.  D., 

J-  Professor  of  the  Principles  and  Practice  of  Medicine  in  BelJevue  Hospital  Med.  College,  X.  Y. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  extra  cloth,  $4  60.     (Just  Issued.) 


Premising  this  observation  of  the  necessity  of  each 
student  and  practitioner  making  himself  acquainted 
with  auscultation  and  percussion,  we  may  state  our 
honest  opinion  that  Dr.  Flint's  treatise  is  one  of  the 
most  trustworthy  guides  which  he  can  consult.  The 
style  is  clear  and  distinct,  and  is  also  concise,  being 
free  from  that  tendency  to  over-refinement  and  unne- 
sessary  minuteness  which  characterizes  many  works 
on  the  same  subject. — Dublin  Medical  Press,  Feb.  6, 
1867. 

In  the  Invaluable  work  before  us,  we  have  a  book 
of  facts  of  nearly  600  pages,  admirably  arranged, 
dear,  thorough,  and  lucid  on  all  points,  without  pro- 
lixity; exhausting  every  point  and  topic  touched  ;  a 
monument  of  patient  and  long-coutiuued  observation. 


American  medicine. — Atlanta  Med.  and  Surg.  Jour- 
nal, Feb.  1867. 

The  chapter  on  Phthisis  Is  replete  with  Interest ; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint's  style  is  clear  and 
elegant,  and  the  tone  of  freshness  and  originality 
which  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a  place  as  a  standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet,  Jan.  19,  1867. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  the 
practitioner.      Dr.    Flint    enriches  his  subject  with 


which  does  credit  to  its  author,  and  reflects  honor  on  I  much  solid  and  not  a   little  original  observation. — 

I  Banking's  Abstract,  Jan.  1867. 


B 


T  THE  SAME  AUTHOR. 


A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     In  one  neat  octavo  volume  of 
nearly  500  pages,  with  a  plate  ;  extra  cloth,  $3  50. 


We  question  the  fact  of  auy  receut  American  author 
in  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  willingly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart,  in 


makingan  extended  personal  clinical  study  available 
for  purposes  of  illustratiou,  in  connection  with  cases 
which  have  been  reported  by  other  trustworthy  ob- 
servers.— Brit,  and  For.  Med.-Chir.  Review. 


pHAMBERS  {T.  K.),  M.D., 

^  Consulting  Physician  to  St.  Mary's  Hospital,  London,  &o. 

THE  INDIGESTIONS ;  or.  Diseases  of  the  Difjestive  Orfrans  Functionally 

Treated.     Second  American,  from  the  second  and  revised  English  Edition.     In  one  hand- 
some octavo  volume  of  over  300  pages,  extra  cloth,  $3  00.      {Now  Ready.) 
He  is  perhaps  the  most  vivid  and  brilliant  of  living  [  and  practical  skill — that  his  success  as  a  teacher  or 


medical  writers;  and  here  he  supplies,  in  a  graphic 
series  of  illu.strations,  bright  sketches  from  his  well- 
Slored  portfolio.  His  is  an  admirable  clinical  book, 
like  all  that  he  publishes,  original,  brilliant,  and  in- 
teresting. Everywhere  he  is  graphic,  and  his  work 
supplies  numerous  practical  hints  of  much  value. — 
Edinhurgh  Med.  and  Surg.  Journal,  Nov.  1867. 

Associate  with  this  the  rare  faculty  which  Dr. 
Chambers  has  of  infusing  an  enthusiasm  in  his  sub- 
ject, and  we  have  in  this  little  work  all  the  elements 
which  make  it  a  model  of  its  sort.    We  have  perused 


literary  expositor  of  the  medical  art  consists ;  and  the 
volume  before  us  is  a  belter  illustration  than  its  au- 
thor has  yet  produced  of  the  rare  degree  in  which 
those  combined  qualities  are  at  his  command.  Next 
to  the  diseases  of  children,  there  is  no  subject  oh 
which  the  young  practitioner  is  oftener  consulted,  or 
on  which  the  public  are  more  apt  to  f>irra  their 
opinions  of  his  professional  skill,  than  the  various 
phenomena  of  indigestion.  Dr.  Chambers  comes  moat 
opportunely  and  effectively  to  his  assistance.  In  fact, 
there  are  few  situations  in  which  the  commencing 
practitioner  can  place  himself  iu  which  Dr.  Cham- 


tt  carefully;  have  studied  every  page;  our  interest  ,  praciiiiouer  can  p.ace   ui  nseu  .u   w....,u  x...  v.,.au^ 
in  the  subject  has  been  intensified  as  we  proceeded,     l>ers'  conclusions  on  digestion  will  not  be  of  service, 
and  we  are  enabled  to  lay  it  down  with  unqualified    -London  Lancet,  February  23,  1807. 
praise.— iV.  Y.  Med.  Record,  April  l.-i,  1867.  j      ^his  is  one  of  the  most  valuable  works  which  it 

It  is  in  the  combination  of  thesequalities — clearand  j  has  ever  been  our  good  fortune  to  receive. — London 
vivid  expression,  with  thorough  scientific  knowledge  ■  Med.  Mirror,  Feb.  1867. 


-nillNTON  (  WILLIAM),  M.  D.,  F.  R.  S. 
LECTURES  ON  THE  DISEASES  OF  THE  STOMACH;   with  an 

Introduction  on  its  Anatomy  and  Physiology.     From  the  second  and  enlarged  London  edi- 
tion.    With  illustrations  on  wood.      In  one  handsome  octavo  volume  of  about  300  pagea, 
extra  cloth.     $3  25.     {Just  issued.) 
Nowhere  can  be  found  a  more  full,  accurate,  plain,  I      The  most  complete  work  in  our  language  upon  th« 
and  instructive  history  of  these  diseases,  or  more  ra-  1  diagnosis  and  treatment  of  these  puzzling  and  Impor- 
(jciiial  views  respecting  their  pathology  and  therapeu-     taut  dioeases. — Boston  Med.  and  Surg.  Journal,  Hov. 
tics. — Am.  Joum.  of  the  Med.  Sciences,  April,  186.1.     |  1865. 


JJABERSHON  {S.  0.),  M.D. 

PATHOLOGICAL  AND  PRACTICAL  OBSERVATIONS  ON  DIS 

EASES  OF  THE  ALIMENTARY  CANAL,  (ESOPHAGUS 


INTESTINES.     With   illustrations  on  wood, 
pages,  extra  cloth.     $2  50. 


STOMACH,  CECUM,  AND 
In  one  handsome   octavo  volume  of  312 


H 


UDSON-  (A.),  M.D.,  M.  R.I. A., 

Physician  to  the  Menlh  No.ij)ilal. 

LECTURES  ON  THE  STUDY  OF  FEVER.     In  one  vol.  8vo. 
iishing  in  the  "Mbdical  News  and  Libkaby''  for  1867  and  1868.) 


(Pub- 


1! 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


ROBERTS  (  WILLIAHf),  M.  D.. 

-*■*'  Lecturer  on  Medicine  in  the  ManCJie/iter  School  of  3fedioine,  &c. 

A  PRACTICAL  TREATISE    ON  URINARY  AND   RENAL   DIS- 

EASES,  including  Urinary  Deposits.     Illustrated  by  numerous  cases  and  engravings.     In 

one  very  handsome  octavo  volume  of  516  pp.,  extra  cloth.     $4  50.     {Just  Issned.) 

In  carrying  out  this  design,  he  has  not  only  made  ]  sive  work  on  urinary  and  renal  diseases,  considered 

good  use  of  his  own  practical  knowledge,  hut  has  i  in  their  strictly  practical  aspect,  that  we  possess  ia 

brought  together  from  various  sources  a  vast  amount  j  the    English    language. — British    Medical    Journai, 


of  information,  some  of  which  is  not  generally  pos- 
sessed by  the  profession  in  this  country.  We  must 
now  bring  our  notice  of  this  book  to  a  close,  re- 
gretting only  that  we  are  obliged  to  resist  the  temp- 
tation of  giving  further  extracts  from  it.  Dr.  Roberts 
has  already  on  several  occasions  placed  before  the 
profession  the  results  of  researches  jnade  by  him  on 
various  points  connected  with  the  urine,  and  had  thus 
led  us  to  expect  from  him  something  good — in  which 
expectation  we  have  been  by  no  means  disappointed. 
The  book  is,  beyond  question,  the  most  comprehen- 

,^*^  "  Bird  on  Urinary  Deposits,"  being  for  the  present  out  of  print,  gentlemen  will  find  in  tb« 
above  work  a  trustworthy  substitute. 


Dec.  9,  1S6.3. 

We  have  read  this  book  with  much  satisfaction. 
It  will  take  its  place  beside  the  best  treatises  in  our 
language  upon  urinary  pathology  and  therapeutics. 
Not  the  least  of  its  merits  is  that  the  author,  unlike 
some  other  book-makers,  is  contented  to  withhold 
much  that  he  is  well  qualified  to  discuss  in  order  to 
impart  to  his  volume  such  a  strictly  practical  churao- 
ter  as  cannot  fail  to  render  it  popular  among  British 
readers. — London  Med.  Times  and  Gazette,  March 
17,  1866. 


MORL.\ND  ON  RETENTION  IN  THE  BLOOD  OF 
THE  ELEMENTS  OF  THE  URINARY  SECRE- 
TION.    1  vol.  Svo.,  extra  cloth.    75  cents. 

BLOOD  AND    URINE  (MANUALS  ON).     By   J.  W. 

TONES  [0.  HANDFIELD),  M.  D., 

^  Phyxician  to  St.  Mary's  Hosjiital,  &c. 

CLINICAL    OBSERVATIONS 

DISORDERS.     Second  American  Edition. 

extra  cloth,  $-3  25.  (Just  Issued.) 
Taken  as  a  whole,  the  work  before  us  furnishes  a 
Bbort  but  reliable  account  of  the  pathology  and  treat- 
ment of  a  class  of  very  common  but  certainly  highly 
absoure  disorders.  The  advanced  student  will  find  it 
a  rich  mine  of  valuable  facts,  while  the  medical  prac- 
titiocer  will  derive  from  it  many  a  suggestive  hint  to  I 
aiil  him  in  the  diagnosis  of  "nervous  cases,"  and  in 
detr  rmiiiing  the  true  indications  for  their  ameliora- 
tion or  cure. — Amer.  Journ.  Med.  Set,  Jan.  1867.         | 


Griffth,  G.  0.  Ree.'?e,  and   A.  Markwick.     1  vol. 
12mo  ,  extra  cloth,  with  plates,     pp.  460.     $1  2i>. 
BUDD  ON  DISEASES  OF  THE  LIVER.  Third  editiott. 
1  vol.  8vo.,  extra  cloth,  with  four  beautifully  colored 
plates,  and  numerous  wood-cuts.     pp.  .500.    $4  00. 


ON    FUNCTIONAL    NERVOUS 

In  one  handsome  octavo  volume  of  348  pages, 

We  must  cordially  recommend  it  to  the  profession 
of  this  country  as  supplying,  in  a  great  measure,  a 
deficiency  which  exists  in  the  medical  literature  of 
the  English  language. — Jfew  York  Med.  Journ.,  ApsU, 
1867. 

The  volume  is  a  most  admirable  one — full  of  hints 
and  practical  suggestions.  —  Canada  Med.  Journal, 
April,  1867. 


HARRISON'S    ESSAY    TOWARDS    A    CORRECT 
THEORY  OK  THE  NERVOUS  SYSTEM.      In    one 

octavo  volume  of  2U2  pp.     %\   ')0. 
SOLLY  ON  THE  HUMAN  BRAIN:  its  Structure,  Phy- 
siology, and  Dise.'tses.     From  the  Second  and  much 
enlarged  London  edition.     In  one  octavo  volume  of 
500  pages,  with  120  wood-cuts;  extra   cloth.    $2  50. 


BUCKNILL  AND  TUKES  MANUAL  OF  PSYCHO- 
LOGICAL MKDICINE;  containing  the  History, 
Nosology,  Description,  Statistics,  Diagnosis,  Patho- 
logy, and  Treatment  of  Insanity.  With  a  Plate. 
In  one  handsome  octavo  volume,  of  .536 pages,  extra 
cloth,     ifcl  25. 


S 


LADE  [D.  D.),  M.D. 

DIPHTHERIA;  its  Nature  and  Treatment,  with  an  account  of  the  His- 
tory of  its  Prevalence  in  various  Countries.  Second  and  revised  edition.  In  one  nea* 
royal  12mo.  volume,  extra  cloth.     $1  25.     {Just  issued.) 


SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE-  j 
JIEDIABLE  STAGES.  In  one  neat  octavo  volume  I 
of  254  pages,  extra  cloth.     *2  25. 

SALTER  ON  ASTHMA  ;  its  Pathology,  Causes,  Con- 
sequences, and  Treatment.  In  one  volume  octavo, 
extra  cloth.     $2  50. 

BUCKLER  ON  FIBRO-BRONCHITIS  AND  RHEU- 
MATIC PNEUMONIA.  In  one  octavo  vol.,  extra 
cloth,  pp   150.     $1   2.5. 

FISKE  FUND  PRIZE  ESSAYS.— LEE  ON  THE  EF- 
FECTS OF  CLIMATE  ON  TUBERCULOUS  DIS- 
EASE.    AJS'D  WARREN  ON  THE  INFLUENCE  OF 


PREGNANCY  ON  THE  DEVELOPMENT  OF  TH- 
BEUCLES.  Together  in  one  neat  octavo  volume 
extra  cloth,     *1  00. 

HUGHES'  CLINICAL  INTRODUCTION  TO  AUS- 
CULTATION AND  OTHER  MODES  OF  PHYSICAI. 
DIAGNOSIS.  Second  edition.  One  volume  royal 
12mo.,  extra  cloth,  pp.  304      *!  25. 

WALSHE'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  THE  HEART  AND  GREAT  VESSEL^ 
Third  American,  from  the  third  revised  and  much 
enlarged  London  edition.  In  one  handsome  octavo 
volume  of  420  pages,  extra  cloth.     $3  00. 


TYONS  [ROBERT  D.),  K.  C.  C. 
A  TREATISE  ON  FEVER;  or,  Selections  from  a  Course  of  Lectures 

on  Fever.    Being  part  of  a  Course  of  Theory  and  Practice  of  Medicine.    In  one  neat  octavo 
volume,  of  362  pages,  extra  cloth.     $2  25. 


CLYMER  ON   FEVERS;    THEIR   DIAGNOSIS,  PA- 

TROLOOY  AND  TREATMENT.  lu  One  octavo  volume 
of  riOO  pages,  leather.     $1  75. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
extra  cloth.     $2  50 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in  its 
Historical,  Pathological,  Etiological,  and  Therapeu- 
tical Relations.  Including  a  Sketch  of  the  Disease 
as  it  has  occurred  in  Philadelphia  from  1699  to  1854, 


with  an  examination  of  the  connections  between  it 
and  the  fevers  known  under  the  same  name  in  othejr 
parts  of  temperate  as  well  as  in  tropical  regiona^ 
In  two  large  and  handsome  octavo  volumes,  of 
nearly  1500  pages,  extra  cloth,  $7  00 
LA  ROCHE  ON  PNEUMONIA  ;  its  Supposed  Conneo- 
tion.  Pathological,  and  Etiological,  with  .\utumnal 
Fevers,  including  an  Inquiry  into  the  Existence  and 
Morbid  Agency  of  Malaria.  In  one  handsome  o!»- 
tavo  volume,  exira  cloth,  of  500  pages.     Price  $3  00. 


Henry  C.  Lea's  Publications — ( Venereal  Diseases,  etc.). 


19 


jyUMSTEAD  {FREEMAN  J.),  M.D., 

J-^        PruftHHor  of  Venereal  JJi.^eases  at  the  Col.  of  Phys.  and  Surg.,  New  York,  &c. 

THE   PATHOLOGY  AND   TREATMENT   OF   VENEREAL  DIS- 

EASES.     Includino;  the  results  of  recent  investigations  upon  the  subject.     A  new  and  re- 
Tised  edition,  with  illustrations.'     In  one  large  and  handsome  octavo  volume  of  640  pages, 
extra  cloth,  $5  00.      [Lately  Issticd.) 
During  the  short  time  which  has  elapsed  since  the  appearance  of  this  work,  it  has  assumed  the 
position  of  a  recognized  authority  on  the  subject  wherever  the  language  is  spoken,  and  its  tran.«la- 
tion  into  Italian  shows  that  its  reputation  is  not  confined  to  our  own  tongue.     The  singular  clear- 
ness with  which  the  modern  doctrines  of  venereal   diseases  are  set  forth  renders  it  admirably 
adapted  to  the  student,  while  the  fulness  of  its  practical  details  and  directions  as  to  treatment 
makes  it  of  great  value  to  the  practitioner.     The  few  notices  subjoined  will  show  the  very  high 
position  universally  accorded  to  it  by  the  medical  press  of  both  hemispheres. 
Well  known  as  one  of  the  best  authorities  of  the     which  has  long  been  felt  in  English  medical  literature. 


present  day  on  the  subject. — British  and  For.  Med.- 
Giiiriirg.  Review,  April,  1S66. 

A  regular  store-house  of  special  information. — 
London  Lancet,  Feb.  24,  18()6. 

A  remarlcably  clear  and  fall  systematic  treatise  on 
the  whole  subject. — Land.  Med.'  Times  and.  Gazette. 

The  best,  complelest,  fullest  monograph  on  this 
subject  in  our  language. — Britiish  American  Journal. 

ladi-^pensable  in  a  medical  library. — Pacific  Med. 
aaid  Surg.  Journal. 

We  have  no  doubt  that  It  will  supersede  in  America 
every  other  treatise  on  Venereal. — San  Francisco 
Med.  Press,  Oct.  ISB-t. 

A  perfect  compilation  of  all  that  is  worth  knowing 
on  venereal  diseases  in  general.     It  fills  up  a  gap 


■Brit,  and  Foreign  Med.-Chirnrg .  Review,  Jan.,  'W>. 

We  Tiave  not  met  with  any  which  so  highly  merits 
our  approval  and  praise  as  the  second  edition  of  Dr. 
Bumstead's  work. — Glasgow  Med.  Journal,  Oct.  ISB-k 

We  know  of  no  treatise  in  any  language  which  is 
its  equal  in  point  of  completeness  and  practical  sim- 
plicity.—  Boston  Medical  and  Surgical  Journal, 
Jan.  30,  1S6-1. 

The  book  Is  one  which  every  practitioner  should 
have  in  his  possession,  and,  we  may  further  say,  the 
o«/»/book  upon  the  subject  which  he  should  acknow- 
ledge as  competent  authority. — Buffalo  Medical  and 
Surgical  Journal,  July,  1S64. 

The  best  work  with  which  we  are  acquainted,  and 
the  most  convenient  handbook  for  the  bu.sy  practi- 
tioner.—  Cincinnati  Lancet,  July,  1864. 


T>OMSTEAD  [FREEMAN  J.), 

-*-''       Professor  of  Venereal  Diseases  in  the  Co 


flULLERIER  [A.),  ond 

^  Surgeon  to  the  Hdpital  du  Midi.         -  -'■''       Professor  of  Venereal  Diseases  in  the  College  of 

Physicia.ns  and  Surgeons,  N.  Y. 

AN     ATLAS    OF    VENEREAL    PTSE.\SES.       Translated    and    Edited    by 

Freem.\n  J.  BuMSTEAT).  To  be  issued  in  five  parts,  at  Three  Dollars  e.nch,  making  a  large 
imperial  4to.  volume  of  oven  .300  pages,  double-columns,  with  26  plates,  containing  about 
150  figures,  beautifully  colored,  many  of  them  the  size  of  life. 

Parts  I.,  II.,  and  III.  are  now  ready. 

Parts 'IV.  and  V.  are  in  a  state  of  forw.ard  progress,  and  will  be  issued  at  short  intervals. 

As  the  successor  of  Ricord  in  the  great  Venereal  Hospital  of  Paris,  M.  Cullerier  has  enjoyed 
specitil  advantages  for  the  present  undertaking,  and  his  series  of  illustrations,  though  only  recently 
finished,  is  already  recognized  as  the  most  complete  and  comprehensive  that  has  yet  appeared  on 
this  subject.  In  reproducing  these  plates  every  care  has  been  had  to  pre.«erve  their  artistic  finish 
and  accuracy,  and  they  are  confidently  presented  as  equal  to  anything  that  has  yet  been  produced 
in  this  country.  The  reputation  of  Dr.  Bumstead  as  a  writer  and  syphilographer  is  too  well  known 
to  require  other  guarantee  for  the  fidelity  of  the  translation  or  the  value  of  the  additions  introduced. 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 

*4*  A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


This  is  a  very  handsome  edition  in  English  of  a 
well  known  and  highly  valued  French  publication. 
That  Dr.  Bumstead.  the  author  of  by  far  the  best  and 
most  popular  treatise  on  venereal  diseases  in  the 
English  language,  should  think  it  i)roper  to  translate 
Willi  edit  this  ono,  speaks  more  highly  in  its  favor  than 
atiything  that  can  be  said.  It  is  a  judgment  e.x  ca- 
OiedrH.  The  translation  is  an  excellent  one.  The 
plates  in  the  tirst  Part  represent  blenuorrhagia  and 
its  complications,  swelled  testicle,  and  gonorrhieal 
ogththaluiia.  They  are  admirably  and  anistically  ex- 
ecuted. Indeed  they  are  superior  to  any  illustrations 
(rf  the  kind  hitlierlo  exccut»-d  in  this  country  The 
uoles  added  by  Dr.  Huiiistead  enliauce  the  value  of 
tiie  work.  The  whole  getting-up  of  this  publication 
is  of  rare  excellence,  and  most  creditable  to  all  cun- 
cej-ned. — Am.  Journ.  of  Med.  Sciences,  April,  1S6S. 

A  magniflcont  work,  in  the  best  style  of  artistic 
Olustration. — Chicago  Med.  Journal,  April,  186S. 


knowfrom  personal  examination.  Theappearsnce  of 
the  work  in  parts  places  it  within  the  reach  of  all,  and 
when  complotod  it  will  be  a  mi>st  valuable  accession 
to  our  literature. — N.  1'.  .Veil.  Journal,  April,  1.'^^1S. 

This  is  probably  the  handsomest  work  of  its  class 
ever  published  in  this  country. — Boston  Med.  and 
Surg,  .lournal,  .\pril  l.'),  IStiS. 

The  two  parts  thus  published  are  illustrated  by 
plates,  than  which  none  superior  have  been  issued 
from  the  press;  in  fact,  in  this  country,  no  more 
magnificent  work  bus  ever  been  published.  Infinite 
credit  is  due  the  publisher  and  translator  that  they 
should  have  placed  before  the  profession,  in  such  a 
style,  so  valuablo  a  production. — St.  Louis  Med.  Re- 
porter, May,  lSt)8 

This  is  one  of  the  most  elegantly  published  and 
valuable  works  that  have  been  ipprintcd  and  edited 
in  this  country,  relating  to  the  loathsome,  though  im- 
I)ortant,  class  of  venereal  diseases.     The  author  and 


We  desire  now  oKpeclally  to  call  the  attention  of  ,  ^,,1,0^  .^^„  ^lj,50  „„.„  „,■  flxporionoo  and  emineLt  ahi- 
tlie  profession  to  the  appearance  of  this  niugnilicent  ,  my.   ^qj  ^q  fr<,piy  commend  the  product  of  their 
w..rk.     The   plates  in  ehromo-lithography  are  most  ,  i^f.^^s  to  the  general  patmuago  of  the  profession.— 
admirably  executed,  and  compare  very  favorably  in     Chicago  Med.  Ejximiner,  May,  IStiS. 
dijitinctness  and  brilliancy  with  the  originals,  as  we  | 


ALLEMAND  AND   WILSON. 

'a    P  II  a  otto  a  L  TREATISE 

AND  tre.\t.mi:nt  of 

edited  by  Hknrv  J 


ON    THE    CAFSES,    SYMPT0:\rS, 

SPRR.MATORRHOyv.     By  M.  Lxi.t.KMANn.     Tianslated  and 
McDoi'OAl.L.      Fifth  Aineriean  edition.     To  which  is  a<lded ON 


DISEASES  OF  TIIE  VESICUL.E  SE.MINALES.  and  tiikik  AssoriAXKD  oroan.s.  With 
Bpeciul  reference  to  the  Morbid  Secretions  of  the  Prostatic  and  Urethral  Mucous  Membrane. 
By  Mauris  Wilson,  M.D.    In  one  neat  octavo  volume,  of  about  400  pp.,  extra  cloth,  $2  73. 


20 


Henry  C.  Lea's  Publications — (Diseases  of  the  Skin). 


jyiLSON  {ERASMUS),  F.R.S., 

ON  DISEASES  OF  THE  SKIN.     With  Hlustrations  on  wood.    Sev- 

enth  American,  from  the  sixth  and  enlarged  English  edition.     In  one  large  octavo  volume 
of  over  800  pages,  $5.     (Notv  Ready.) 

A  SERIES  OF  PLATES  ILLUSTRATING  "WILSON  ON  DIS- 
EASES OF  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.  Price,  in  extra  cloth,  $5  50. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Extra  cloth,  $10. 

From  the  Preface  to  the  Sixth  English  Edition. 
The  present  edition  has  been  carefully  revised,  in  many  parts  rewritten,  and  our  attention  hna 
been  specially  directed  to  the  practical  application  and  improvements  of  treatment.  And,  in 
conclusion,  we  venture  to  remark  that  if  an  acute  and  friendly  critic  should  discover  any  differ- 
ence between  our  present  opinions  and  those  announced  in  former  editions,  we  have  only  to  ob- 
serve that  science  and  knowledge  are  progressive,  and  that  we  have  done  our  best  to  move  onwawi 
with  the  times. 

The  industry  and  care  with  which  the  author  has  revised  the  present  edition  are  shown  by  the 
fact  that  the  volume  has  been  enlarged  by  more  than  a  hundred  pages.  In  its  present  improved 
form  it  will  therefore  doubtless  retain  the  position  which  it  has  acquired  as  a  standard  and  classical 
authority,  while  at  the  same  time  it  has  additional  claims  on  the  attention  of  the  profession  aa 
the  latest  and  most  complete  work  on  the  subject  in  the  English  language. 

We  can  safely  recommend  it  to  the  profession  as 


Such  a  work  as  the  one  before  ns  is  a  most  capital 
and  accfiplable  help.  Mr.  Wilson  hag  long  been  held 
as  high  authority  in  this  department  of  medicine,  and 
his  book  on  disease.s  of  the  skin  has  long  been  re- 
garded as  one  of  the  best  text-books  extant  on  the 
subject.  The  present  edition  is  carefully  prepared, 
and  brought  up  in  its  revision  to  the  present  time.  In 
this  edition  we  have  also  i  ncladed  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi- 
tion published  Heparately.  There  are  twenty  of  these 
plate-i,  nearly  all  of  th^m  colored  to  nature,  and  ex- 
hibiting with  great  fldelily  the  various  groups  of 
diseases  treated  of  In  the  body  of  the  work. — Cin- 
oinnati  Lancet,  June,  186.3. 

No  one  treating  skin  diseases  should  be  without 
a  copy  of  this  standard  work. —  Canada  Lancet. 
August,  1863. 


the  best  work  on  the  subject    now  in   existence  in 
the  English  language. — Medical  Times  and  Gazette. 

Mr.  Wilson's  volume  Is  an  excellent  digest  of  the 
actual  amount  of  knowledge  of  cutaneous  diseases; 
it  includes  almost  every  fact  or  opinion  of  importance 
counected  with  the  anatomy  and  pathology  of  the 
skia.-^Britinh  and  Foreign  Medical  Review. 

These  plates  are  very  accurate,  and  are  executiid 
with  an  elegance  and  taste  which  are  highly  creditable 
to  the  artistic  skill  of  the  Amerlcua  artist  who  executed 
them. — St.  Lnuis  Med.  Journal. 

The  drawings  are  very  perfect,  and  the  finish  and 
coloring  artistic  and  correct;  the  volume  Is  an  indis- 
pensable companion  to  the  book  it  illustrates  and 
completes. — Oliarleston  Medical  Journal. 


J^Y  THE  SAME  AUTHOR. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Di9- 

EASES  OF  THE  SKix.    In  One  very  handsome  royal  12mo.  volume.    $.3  50.    (Lately  Issued.) 
-DY  THE  SAME  AUTHOR.  

HEALTHY  SKIN;   a  Popular  Treatise  on  the  Skin  and  Hair,  their 

Preservation  and  Management.     One  vol.  12mo.,  pp.  291,  with  iilustratione,  cloth.     $1  00. 

JiJELIGAN  {J.MOORE),  M.D.,  M.R.T.A., 

A    PRACTICAL    TREATISE    ON    DISEASES    OF    THE    SKIN. 

Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T.  W.  Belcher,  M.  D. 
In  one  neat  royal  12mo.  volume  of  462  pages,  extra  cloth.     $2  25.     (Jtist  Issued.) 

Of  the  remainder  of  the  work  we  have  nothing  be- 1  This  instructive  litUe  volume  appears  once  more, 
yimd  unqualified  commendation  to  offer.  It  is  so  far  Since  the  death  of  its  di»tingnished  author,  the  study 
the  most  complete  one  of  its  size  that  has  appeared,  of  skin  diseases  has  been  considerably  advanced,  and 
and  for  the  student  there  can  be  none  which  can  com-  the  results  of  these  investigations  have  been  added 
pare  with  it  in  practical  value.  All  the  late  disco-  by  the  present  editor  to  the  original  work  of  Dr.  Nelv- 
veries  in  Dermatology  have  been  duly  noticed,  and  gan.  This,  however,  has  not  so  far  increased  its  bulk 
their  value  justly  estimated  ;  in  a  word,  the  work  is  as  to  destroy  its  reputation  as  the  most  convenient 
fully  up  to  the  times,  and  is  thoroughly  stocked  with  manual  of  diseases  of  the  skin  that  can  be  procured 
most  valuable  information. — New  York  Med.  Record,  by  the  student. — Chicago  Med.  Journal,  Dec.  1866. 
Jan.  lo,  1S67.  1 

nY  THE  SAME  AUTHOR.  

ATLAS   OF    CUTANEOUS    DISEASES.      In   one   beautiful   quarto 

volume,  with  exquisitely  colored  plates,  Ac,  presenting  about  one  hundred  varieties  of 
di.sease.     Extra  cloth,  $5  50. 


The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  difQcult.  Nevertheless, 
Dr.  Neligan  has  certainly,  "as  far  as  possible,"  given 
a  faithful  and  accurate  representation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong.  While 
looking  over  the  "Atlas"  we  have  been  induced  to 
examine  also  the  "Practical  Treatise,"  and  we  are 


Inclined  to  consider  it  a  very  superior  work,  com- 
bining accurate  verbal  description  with  sound  views 
of  the  pathology  and  treatment  of  eruptive  diseases. 
— Glnfigow  Med.  Journal. 

A  compend  which  will  very  much  aid  the  practl- 
tioner  in  this  ditlicult  branch  of  diagnosis.  Taken 
with  the  beautiful  plates  of  the  Atlas,  which  are  re- 
markable for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a  very  valuable  addition  to  the  library 
of  a  practical  man. — Buffalo  Med.  Journal. 


TJILLIER  {THOMAS),  M.D., 

-*-  -*■  Phyidcian  to  the  Skin  Department  of  University  College  Hospital,  &c. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 
In  one  neat  royal  12mo.  volume  of  about  300  pages,  with  two  plates;  extra  cloth,  $2  25. 
(Just  Issued.) 


Henry  C.  Lea's  Publications — (Diseases  of  Children). 


21 


pONDIE  [D.  FRANCIS),  M.  D. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN, 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely- 
printed  pages,  extra  cloth,  $6  25  ';  leather,  $6  25.       {Now  Beady.) 
From  the  Author'' s  Preface. 
In  preparing  for  the  press  this  sixth  edition  of  his  treatise  on  the  Diseases  of  Children,  the  great 
aim  of  the  author  has  been  to  present  a  complete  and  faithful  exposition  of  the  ytathology  and 
therapeutics  of  the  maladies  incident  to  the  earlier  stages  of  existence.     The  entire  work  has 
undergone  a  careful  and  thorough  revision  ;  while  in  the  different  sections  has  been  incorporated 
every  important  observation  in  reference  to  the  diseases  of  which  they  treat,  that  has  been  re- 
corded since  the  appearance  of  the  last  edition.     Every  effort  has  been  made,  and  every  available 
source  of  information  sought  after,  to  render  the  treatise  a  reliable  and  useful  guide  to  the  actual 
gtate  of  medical  knowledge  in  reference  to  all  those  diseases  which  either  exclusively  or  most  usu- 
ally occur  between  birth  and  puberty — diseases  which  form,  in  some  degree,  a  class  apart  from 
those  of  the  adult — and  demand  for  their  cure  a  particular  plan  of  treatment. 

Dr.  Condie  has  been  one  of  tlioHe  who  have  per-   days  by  wandering  through  its  pages,  and  at  the  same 


formed  such  a  service  satisfactorily,  and,  as  a  result, 
his  popular,  comprehensive,  and  practical  work  lias 
received  thitt  high  compliment  of  approval  on  the 
part  of  his  brethren,  which  several  editions  incontes- 
tably  set  forth.  The  present  edition,  which  is  the 
sixth,  is  fully  up  to  the  times  in  the  discussion  of  all 
tliose  points  in  the  pathology  and  treatment  of  infan- 
tile diseases  which  have  been  brought  forward  by  the 
German  and  French  teachers.  As  a  whole,  however, 
the  work  is  the  best  American  one  that  we  have,  and 
in  its  special  adaptation  to  American  practitioners  it 
certainly  has  no  equal. — Ntw  York  Med.  Record, 
March  2,  1868. 

No  other  treatise  on  this  subject  is  better  adapted 
to  the  American  physician.  Dr.  Condie  has  longstood 
before  his  countrymen  as  one  peculiarly  pre-eminent 
in  this  department  of  medicine  His  work  has  been 
80  long  a  standard  for  practitioners  and  medical  stu- 
dents that  we  do  no  more  now  than  refer  to  the  fact 
tliat  it  has  i-eached  its  sixth  edition.  We  are  glad 
occe  more  to  refresh  the  impressions  of  our  earlier 


time  to  be  able  to  recommend  it  to  the  youngest  mem- 
bers of  the  profession,  as  well  as  to  those  who  hava 
the  older  editions  on  tlieir  shelves. — St.  Louis  Med. 
Reporter,  Feb.  15,  1868. 

The  work  of  Dr.  Condie  is  unquestionably  a  very- 
able  one.  It  is  practical  in  its  character,  as  its  title 
Imports;  but  the  practical  precepts  recommended  in 
it  are  based,  as  all  practice  should  be,  upon  a  familiar 
knowledge  of  disease.  The  opportunities  of  Dr.  Con- 
die for  the  practical  study  of  the  diseases  of  children 
have  been  great,  and  his  work  isaproof  that  they  have 
not  been  thrown  away.  He  has  read  much,  but  ob- 
served more  ;  and  we  think  that  we  may  safely  say 
that  the  American  student  cannot  find,  in  his  own 
language,  a  better  book  upon  the  subject  of  whioii  U 
treats. — Am.  Journal  Medical  Sciences. 

We  pronounced  the  first  edition  to  be  the  beat  work 
on  the  diseases  of  children  in  the  English  language, 
and,  notwithstanding  all  that  has  been  published,  we 
still  regard  it  in  that  light. — Medical  Examiner. 


VifEST  {CHARLES),  M.D., 

Physician  to  the  Hospital  for  Sick  Children,  Ac. 

LECTURES  ON   THE   DISEASES   OF  INFANCY  AND  CHILD- 

HOOD.  Fourth  American  from  the  fifth  revised  and  enlarged  English  edition.  In  one 
large  and  handsome  octavo  volume  of  666  closely-printed  pages.  Extra  cluth,  $4  60; 
leather,  $5  60.      (Just  issued.) 

This  work  may  now  fairly  cl.aim  the  position  of  a  standard  authority  and  medical  classic.  Five 
editions  in  England,  four  in  America,  four  in  Germany,  and  translations  in  French,  Danish, 
Dutch,  and  Russian,  show  how  fully  it  has  met  the  wants  of  the  profession  by  the  soundne.ss  of  its 
views  and  the  clearness  with  which  they  are  presented.  Few  practitioners,  indeed,  have  had  the 
(»]5portunities  of  observation  and  experience  enjoyed  by  the  Author.  In  his  Preface  he  remarks, 
"  The  present  edition  embodies  the  results  of  1200  recorded  cases  and  of  nearly  400  post-mortem 
eKaniinations,  collected  from  between  30,000  and  40,000  children,  who,  during  the  past  twenty- 
six  years,  have  come  under  my  care,  either  in  public  or  in  private  practice."  The  universal  favor 
with  which  the  work  has  been  received  shows  that  the  author  has  made  good  use  of  these  unusual 
advantages. 

Of  all  the  English  writers  on  the  disea.ses  of  chil- 1  affording  the  reader  much  pleasure,  even  Independen 
dron,  there  is  no  one  so  entirely  satisfactory  to  us  as  |  of  that  which  arises  from  the  acquisition  of  valuable 
"  "  truths. — Cincinnati  Jour,  of  Medicine,  Mixrch,  iS^ii. 

We  have  long  regarded  it  as  the  most  scientific  and 
practical  book  on  diseases  of  children  which  has  yet 
appeared  in  this  country. — Buffalo  Medical  Journal. 

Dr.  West's  book  is  the  best  that  lias  ever  beea 
written  in  the  English  language  on  the  diseases  of 
infancy  and  «hildhood. — Culumhus  Review  of  Med. 
and  Su,rgery. 

There  is  no  part  of  the  volume,  no  subject  on  which 
it  treats  which  does  not  exhibit  the  keen  perception, 
the  clear  judgment,  and  the  sound  reasoning  of  tlte 
author.  It  will  be  found  a  most  useful  guide  to  the 
young  practitioner,  directing  him  in  his  managemeut 
of  children's  diseases  in  the  clearest  possible  manner, 
and  enlightening  him  on  many  a  dubious  pathological 
point,  while  the  older  one  will  find  in  it  many  a  sug- 
gestion and  practical  hint  of  groat  value. — Brii.  Am. 
Med.  Journal. 


Dr.  West.  For  years  we  have  held  his  opinion  a 
judicial,  aud  have  regarded  him  as  one  of  the  highest 
living  authorities  in  the  difficult  department  of  medi- 
cal science  in  which  he  is  most  widely  known.  His 
writiugs  are  characterized  by  a  sound,  practical  com- 
mon sense,  at  the  same  time  that  they  bear  the  marks 
of  the  most  laborious  study  and  investigation.  We 
commend  it  to  all  as  a  most  reliable  adviser  on  many 
occasions  when  many  treatises  on  the  same  subjects 
will  utterly  fail  to  help  us.  It  is  supplied  with  a  very 
•opious  general  index,  and  a  special  index  to  the  for- 
mula; scattered  throughout  the  work. — Boston  Med. 
and  Surg.  Journal,  April  26,  1S06. 

Dr.  West's  volume  is,  in  our  opinion,  Incomparably 
the  best  authority  upon  the  maladies  of  children 
that  the  practitioner  can  consult.  Withal,  too — a 
minor  matter,  truly,  but  still  not  one  that  slioald  be 
neglected — Dr.  West's  composition  possesses  a  pecu- 
liar charm,  beauty  and  clearness  of  exprossiou,  thus 


B 


EWEES  {WILLIAM  P.),  M.D., 

Late  Profe^Hsor  of  Midwifery,  Ac,  in  the  University  of  Pennsi/lrania,  *c. 

A  TREATISE  ON  THE  PHYSICAL  AND  MEDICAL  TREAT- 
MENT OF  CHILDREN.  Eleventh  edition,  with  the  author's  last  improvements  and  cor- 
rections.    In  one  octavo  volume  of  548  pages.     $2  80. 


22 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


/THOMAS  [T.  GAILLARD),  M.  D., 

-*•  Priifissor  of  ObHetries,  <tc  t?i.  the  College  nf  Physicians  and  Surgeons,  N.  F.,  &c. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.     In 

one  large  and  handsome  octavo  volume  of  over  600  pages,  with  219  illustrationa,  ext»3 
cloth,  $5;  leather,  $6.      {Now  Ready.) 

From  the  Preface. 

"  This  work  was  undertaken  with  the  conviction  that  a  treatise,  such  as  that  which  the  Author 
has  aimed  to  prepare,  was  needed  as  a  text-book  for  the  American  student,  and  as  a  book  of 
reference  for  the  busy  practitioner. 

"  No  department  of  medicine  has  made  greater  advances  within  the  last  few  years  than  Gyne- 
cology ;  yet  the  record  of  its  progress  is,  for  the  most  part,  to  be  found  only  in  special  monographs, 
journals,  transactions  of  societies,  <fec.,  and  is  thus  inaccessible  to  the  mass  of  the  profession  in 
this  country.  It  has,  therefore,  seemed  to  the  author  that  a  volume  which  should,  within  a 
limited  spiice,  present  the  latest  aspect  of  the  subject  in  a  systematic  form,  could  scarcely  fail  to 
prove  useful,  while  his  position  for  the  last  thirteen  years  as  a  teacher  in  this  department  has 
encouriiged  him,  in  the  hope  that  his  familiarity  with  the  needs  of  the  student  may,  to  some  extent, 
have  fitted  him  to  undertake  the  task." 


The  best  text-book  for  students,  and  a  perfect  vade 
mecum  to  the  gynecologist  — N.  Y.  Journal  of  Obntet- 
rics.  May,  1S68. 

We  have  receutly  been  almost  flooded  by  works 
from  Ameiican  sources  on  the  allied  bubjectsof  ob- 
stetrics and  gynecology.  Nor  has  rjuanlity  alone  been 
the  most  noticeable  feature  connected  with  them,  for 
their  quality  lias  invariably  been  of  thelilgheit.  Dr. 
Thomas's  work  is  no  exception  to  this  rule  ;  it  is  pre- 
eminently .soiiud  and  practical,  evincing  much  re- 
search and  great  clinical  experience  It  Is  further 
illnstraied  by  upwards  of  two  hundred  engravings, 
some  of  them  of  great  value. — London  Med.  Times 
and  Giz.,  April  2-5,  1868. 

Tiic  bonk  of  Prof  Thomas  is  well  calculated  -to  do 
ftway  with  this  latter  objection,  and  to  accomplish 
more  towards  the  establishment  of  a  rational  system 
of  uterine  therapeutics  than  any  other  work  of  its 
size  in  any  language.  VVe  have  rarely  read  any  trea- 
tise upon  a  medical  topic  that  has  given  us  better 
satisfaciion,  or  impressed  us  with  the  tituess  of  an  au- 
thor for  the  proper  performance  of  a  most  responsible 
task.  It  ispt-rliaps  unnecessary  for  us  to  commend  the 
work  most  heartily  to  every  one  wlio  is  or  may  be 
liable  to  treat  uterine  diseases. — N.  York  MedicM  Re- 
oard,  April  !.'•,  IStSS. 

A  wiirk  which  will  certainly  add  to  the  reputation 
of  its  author,  and  come  into  >,'pneral  use  in  this  coun- 
try as  a  text-book.  The  style  is  exceedingly  clear 
and  concise,  and  the  views  expressed  eminently  prac- 
tical and  scientific  — Quarterly  Joum.  of  Paycluil. 
Medicine,  April,  1868. 

The  work  is  concise  and  practical,  avoiding  the  dis- 
anssioii  of  unsettled  questions,  but  giving  a  judicious 
resume  of  known  facts. — Chicago  Med.  Journal, 
A^ril,  1S68. 

We  are  led  to  believe  that  it  is  the  best  work  that 
has  yet  appeared  on  the  diseases  of  women.  There 
is  about  It  a  precision  and  accuracy,  a  fulness  and 


completeness,  a  clearness  and  simplicity,  to  be  found 
in  no  other  book  on  the  same  subject  wilhiu  onr 
knowledge  ;  its  views  on  uterine  pathology  are,  to 
onr  mind,  more  consonant  with  reason  and  common 
sense  than  any  other  we  have  seen.  Enjoying  fine 
opportunities  in  an  extensive  field  of  observation.  Dr. 
Thomas,  as  an  author,  has  fully  sustained  liis  high 
reputation  as  a  teacher.  We  have  no  hesitation  in 
strongly  recommending  it  to  the  profession  as  the  best 
exposition  yet  published  of  the  subjects  (jf  which  it 
treats. — Atlatila  Med.  and  Surg.  Journal,  April,  '68. 
In  no  work  with  which  we  are  acc|nainted.  is  theirs 
to  be  found  so  full  nnd  complete  an  exhibit  of  the  iii»- 
proved  means  of  diagnosis  of  the  obscure  subjects  of 
gynecology,  or  of  their  more  enlightened  therapy. 
Did  our  space  permit,  we  should  be  glad  to  go  into  au 
extended  review  of  the  work  before  us,  giving  nol 
merely  au  outline  of  the  subjects  treated  of,  but  full 
extracts  from  the  text  itself.  As  it  is,  we  can  only 
recommend  our  readers  to  buy  it,  feeling  convinced 
they  will  be  amply  repaid  for  the  outlay. — Leam.»- 
worth  Medical  JJeialii,  Jlay,  1SG8. 

Indeed,  we  do  not  know  a  better  study  in  briefe* 
space^  not  for  medical  students  merely,  but  for  prac- 
titioners, who  may  really  wish  to  have  light  npou  an 
obscure  pathway,  to  be  trained  in  the  thorough  in- 
vestigation of  diseases  peculiar  to  women,  than  ie 
herein  to  be  found. —  Western  Journal  of  Medicin*, 
May,  1868. 

It  is  a  masterly  risumf  of  what  is  known,  by  an 
experienced  and  honest  observer.  The  Profession 
is  indebted  to  Prof.  Thomas  for  thus  tabulating  th« 
much  that  has  been  accepted  as  valuable  and  reliable 
in  gynecology,  but  this  is  not  by  any  means  all  \.ha 
merit  of  the  work  ;  we  have  his  ample  experience, 
given  in  his  opinions  on  pathology  and  treatment, 
which  carry  conviction  by  the  confidence  we  feel  that 
they  are  the  candid  opinions  of  an  honest  and  compe- 
tent observer. — Humboldt  Med.  Archives,  April,  L868. 


c 


B 


H  cm  CHILL  {FLEETWOOD),  M.  D.,  M.  R.  L  A. 

ON  THE  DISEASES    OF  WOMEN;    including  those  of  Pre,gnancy 

and  Childbed.    A  new  Atnerican  edition,  revised  by  the  Author.    With  Notes  and  Additions, 
by  D.  Francis   Co.ndie,  M.  1).,  author  of  "  A  Practical  Treatise  on  the  Diseases  of  Chil- 
dren."    With  numerous  illustrations.      In  one  large  and  handsome  octavo  volume  of  768 
pages,  extra  cloth,  $4  00;  leather,  $5  00. 
Y  THE  SAME  AUTHOR.  

ESSAYS  ON    THE    PUERPERAL    FEVER,  AND    OTHER   DIS- 

E  V.'^ES  PECULI.AR  TO  W0MP:N.  Selected  from  the  writings  of  British  Authors  previ- 
ous  to  the  close  of  the  Eighteenth  Century.  In  one  neat  octavo  volume  of  about  4&0 
pages,  extra  cloth.     $2  50. 


BROWN  ON  SOME  DISEASES  OF  WOMEN  AD- 
MITTING OF  SLUUilCAL  TREAT.MENT.  With 
handsome  illustratioug.  Cue  volume  8vo.,  extra 
cloth,  pp.  276.     *l  60. 

ASHWELL'S  PK.VCTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Illustrated  by 
Cases  derived  from  Hospital  and  Private  Practice. 
Third  American,  from  the  Third  and  revised  Lon- 
don edition.  In  one  octavo  volume,  extra  cloth, 
of  .528  pages.     ijsS  oO. 

EIGBY  ON  THE  CONSTITUTIONAL  TREATMENT 
OF  FEMALE  DI.^EASE.-^.  In  one  neat  royal  l'_'mo. 
volnme.  extra  cloth,  of  about  2.'>o  paues.     tl  (X). 

DEWEES'S  TREATISE  ON  THE  DISEASES   OF  FE- 


MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  last  improvements  and  correo- 
tions.  In  one  octavo  volume  of  536  pages,  with 
plates,  extra  cloth,  *:i  00. 
COLOMB.\T  DE  L'ISERE  ON  THE  DISEASES  0? 
FE.MALES.  Translated  by  C.  D.  .Meios,  M.  D,  Se- 
cond edition.  In  one  vol.  8vo,  extra  cloth,  with 
numerous  wood-cuts.     pp.  720.     $;1  7.i. 

BENNETT'S  PRACTICAL  TREATISE  ON  INFLAM- 
MATION OF  THE  UTERUS,  ITS  CERVIX  AND 
APPENDAGES,  and  on  its  connection  with  Uterine 
Disease  Sixth  American,  from  the  fourth  and  re- 
vised English  edition.  1  vol.  8vo.,  of  about  iOO 
pages,  extra  cloth.     $3  75. 


Henry  C.  Lea's  Publications — {Diseases  of  Women). 


23 


'W'EST  [CHARLES],  M.D. 

LECTURES  ON  THE  DLSEASES   OF  WOMEN.    Tliinl  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  extra 

cloth.     $3  75;  leather,  $4  75.      (Now  Ready.) 

The  reputation  which  this  volume  has  acquired  as  a  standard  book  of  reference  in  its  depart 

ment,  renders  it  only  necessary  to  say  th;it  the  present  edition  has  received  a  careful  revision  at 

the  hands  of  the  author,  resulting  in  a  considerable  increase  of  size.     A  few  notices  of  previoiw 

editions  are  subjoined. 


The  manner  of  tlie  author  is  excellent,  his  descrip- 
tions graphic  and  perspicuous,  and  his  treatment  up 
to  the  level  of  the  time— clear,  precise,  deliiiite,  and 
marked  by  strong  common  sense.  —  Chiango  3Ied. 
Journal,  Dec.  1861. 

We  cannot  too  highly  recommend  this,  the  second 
edition  of  Dr.  West  s  excellenflpctnres  on  the  dis- 
eases of  females.  We  know  of  no  other  book  on  this 
Mibject  from  which  we  have  derived  as  much  pleasure 
and  instruction.  Every  page  gives  evidence  of  the 
honest,  earnest,  and  diligent  searcher  after  truth.  He 
is  not  the  mere  compiler  of  other  men's  ideas,  but  his 
lectiues  are  the  result  often  years'  patient  investiga- 
tion in  one  of  the  widest  fields  for  women's  diseases — 
St.  Bartholomew's  Hosjiital.  As  a  teacher,  Dr.  West 
is  simple  and  earnest  in  his  language,  clear  and  com- 
prehensive in  his  perceptions,  and  logical  in  his  de- 
ductions.— Cincinnati  Lancet,  Jan.  1862. 

We  have  thus  embodied,  in  this  series  of  lectures, 
one  of  the  most  valuable  treatises  on  the  diseases  of 
the  female  sexual  system  unconnected  with  gestation, 
in  our  language,  and  one  which  cannot  fail,  from  the 
lucid  manner  in  which  the  various  subjects  have 
been  treated,  and  the  careful  discrimination  used  in 
dealing  only  with  facts,  to  recommend  the  volume  to 
the  careful  study  of  every  practitioner,  as  affording 
kis  safest  guides  to  practice  within  our  knowledge. 
We  have  seldom  perused  a  work  of  a  more  thoroughly 
practical  character  than  the  one  before  us.  Every 
page  teems  with  the  most  truthful  aud  accurate  infor- 
mation, and  we  certainly  do  not  know  of  any  other 
work  from  which  the  physician,  in  active  practice, 
can  more  readily  obtain  advice  of  the  soundest  cha- 
racter upon  the  peculiar  diseases  which  have  been 
Blade  the  subject  of  elucidation. — British  Am.  Med. 
Jtiurnal. 


We  return  the  author  our  grateful  thanks  for  tl>« 
vast  amount  of  instruction  he  has  afforded  us.  His 
valuable  treatise  needs  no  eulogy  on  our  part.  His 
graphic  diction  and  truthful  pictures  of  disease  &11 
speak  for  themselves. — Mmlico-Chiriirg.  Seview. 

Most  justly  esteemed  a  standard  work It 

bears  evidence  of  having  been  carefully  revised,  and 
is  well  worthy  of  the  fame  it  has  already  obtained. 
— Dub.  Med.  Quar.  Jour. 

As  a  writer.  Dr.  West  stands,  in  onr  opinion,  se- 
cond only  to  Watson,  the  "Macaulay  of  Medicine;" 
he  possesses  that  happy  faculty  of  clothing  instruo- 
tion  in  easy  garments ;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro- 
vei-b,  along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  hat 
it  is  one  that  will  please  the  great  majority  who  are 
seeking  truth,  and  one  that  will  convince  the  student 
that  he  has  committed  himself  to  a  candid,  saf«,  and 
valuable  guide. — ^V.  A.  Med.-Ghirurg  Review.  , 

We  must  now  conclude  this  bastily  written  sketch 
with  the  confident  assurance  to  onr  readers  that  the 
work  will  well  repay  perusal.  The  cooscientioua, 
painstaking,  practical  physician  is  apparent  on  every 
page. — if.  T.  Journal  of  Medicine. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  tt 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  facile  princejjs  of 
British  obstetric  authors. — Edinburgh.  MeA.  Jiturnal. 

We  gladly  recommend  his  lectures  as  in  the  highest 
degree  instructive  to  all  who  are  interested  in  ob- 
stetric practice. — London.  Lancet. 

We  know  of  no  treatise  of  the  kind  so  complete, 
and  yet  so  compact. — Chicago  Med.  Journal. 


B 


Y  THE  SAME  AUTHOR. 


AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OP 

ULCERATION  OF  THE  OS  UTERI.     In  one  neat  octavo  volume,  extra  cloth.     $1  25. 


31 


EIGS  {CHARLES  D.),  M.  D., 

Late  Professor  of  Ohstttrics,  &c.  in  Jf.ffer.<ion  Medical  College,  Philadelphia. 

WOMAN:    HER  DISEASES  AND  THEIR  REMEDIES.     A  Serios 

of  Lectures  to  his  Cla.ss.     Fourth   and  Improved  edition.     In   one  large  and  beautifully 
printed  octavo  volume  of  over  700  pages,  extra  cloth,  $5  00  ;  leather,  $(>  00. 


Every  topic  discussed  by  the  author  is  rendered  so 
plain  as  to  be  readily  understood  by  every  .student : 
aud,  for  our  owa  part,  we  consider  it  not  only  one  of 


the  most  readable  of  books,  but  one  of  priceless  value 
to  the  practitioner. — H.  Am.  Med.-Ohir.  Re^ncto. 


B 


H 


r  THE  SAME  AUTHOR. 


ON  THE  nature;  SIGNS,  AND  TREATMENT  OF  CHILDBED 

FEVER.     In  a  Series  of  Letters  addressed  to  the  Students  of  his  Class.     In  one  handsom* 
octavo  volume  of  365  pages,  extra  cloth.     $2  00. 

ODGE  {HUGH  L.),  M.D. 

ON  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  Uterus.     With  original  illustrations.     Second  edition,  revised.     In  one  beautifully 

printed  octavo  volume  of  about  500  pages.     (Preparing.) 

the  day — one  which  every  acconchenr  and  physician 
should  most  carefully  read:  for  we  are  persuaded 
that  he  will  arise  from  its  perusal  with  new  ideas, 
which  will  induct  him  into  a  more  raliotial  pnictica 
in  regard  to  many  a  suffering  female  who  may  h.iv« 
placed  her  health  in  his  hands. — British  AiufricoM 
Journal,  Feb.  IStil. 


Indeed,  although  no  part  of  the  volume  is  not  emi- 
nently deserving  of  perusal  and  study,  we  think  that 
tJie  nine  chapters  devoted  to  this  subject  are  espe- 
aially  so,  and  we  know  of  no  more  valuable  mono- 
graph ui)on  the  symptoms,  prognosis,  and  manage- 
ment of  these  annoying  maladies  than  is  constituted 
by  this  part  of  the  work.  We  cannot  but  regard  it  as 
(Mie  of  the  most  original  aud  must  practical  works  of 


s 


IMPSON  {SIR  JAMES  Y.),  M.D. 

CLINICAL  LECTURES  ON  THE  DISEASES  OF  WOMEN.    With 

numerous  illustrations.   In  one  octavo  volume  of  over  500  pnges.    Second  edition,  preparing. 


24 


Henry  C.  Lea's  Publications — {Midwifery). 


JJODGE  {HUGH  L.),  M.D., 

Late  Professor  of  Midwifery,  &c,  in  the  University  of  Pennsylvania,  &c. 

THE  PRIXCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  650  double-columned  pages,  strongly  bound  in  extra  cloth,  $14.  (Lately 
published.) 

We  have  examined  Professor  Hodge's  work  with 
great  satisfaction;  every  topic  is  elaborated  most 
fully.  Tlie  views  of  the  author  are  coraprelieusive, 
and  concisely  .stated.  The  rules  of  piactice  are  judW 
cious,  and  will  enable  the  practitioner  to  meet  every 
emergency  of  obstetric  complication  with  confidence. 
— Chicago  Med.  Journal,  Aug.  1864. 


The  work  of  Dr.  Hodge  is  soraetbing  more  than  a 
simple  presentation  of  Ins  particular  views  in  the  de- 
partment of  Obstetrics  ;  it  is  something  more  than  an 
wdinary  treatise  on  midwifery;  it  is,  in  fact,  a  cyclo- 
psedia  of  midwifery.  He  has  aimed  to  embody  in  a 
single  volume  the  whole  science  and  art  of  Obstetrics. 
An  elaborate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  no  fact  or  principle 
18  left  unstated  or  uaezplained. — Am.  Med.  Times, 
Sept.  .3,  1S64. 

We  should  like  to  analyze  the  remainder  of  this 
ftxcoUent  work,  but  already  has  this  review  extended 
beyond  our  limited  space.  We  cannut  c6nclude  this 
notice  without  referring  to  the  excellent  finish  of  the 
work.  In  typography  it  is  not  to  be  excelled;  the 
paper  is  superior  to  what  is  usually  afforded  by  our 
American  cousins,  quite  equal  to  the  best  of  English 
books.  The  engravings  and  lithographs  are  most 
beautifully  executed.  The  work  recommends  Itself 
for  its  originality,  and  is  in  every  way  a  most  valn- 
Dihle  addition  to  those  on  the  subject  of  obstetrics. — 
(kunuda  Med.  Journal,  Oct.  1S64. 

It  is  very  large,  profusely  and  elegantly  illustrated, 
and  is  tilted  to  take  its  place  near  the  works  of  great 
qbsietricians.  Of  the  American  works  on  the  subject 
it  is  decidedly  the  best. — Kdinb.  Med.  Jour.,  Dec.  't>4. 

***  Specimens  of  the  plates  nnd  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


More  time  than  we  have  had  at  our  disposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by  far  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  t)bstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacijit 
Med.  and  Surg.  Journal,  July,  1864. 

We  have  read  Dr.  Hodge's  book  with  great  plev 
sure,  and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a  whole.  It  is  certainly  highly 
instructive,  and  iu  the  main,  we  believe,  correct.  The 
great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  along  with  the  coiv- 
clusion.s  at  which  he  has  arrived,  point,  we  think, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1864. 


JIANNER  {THOMAS  H),  M.  D., 
ON  THE  SIGNS  AND  I)TSE.\SES  OF   PRKONANCY.     Fir.«t  Amoriean 

from  the  Second  and  Enlarged  Englisl\E<lition.  With  four  colored  plates  and  illu.otrations 
on  wood.  In  one  handsome  octavo  volume  of  about  5UU  pages,  extra  cloth,  $4  25.  (Now 
Ready.) 


The  very  thorough  revision  the  work  has  undergone 
has  added  greatly  to  its  practical  value,  and  increased 
materially  its  etliciency  as  a  guide  to  the  student  and 
to  the  young  practitioner. — Ant..  Juum.  Med.  Sci., 
April,  1868. 

With  the  Immense  variety  of  subjects  treated  of 
and  the  ground  which  they  are  made  to  cover,  the  im- 
possibilicy  of  giving  an  extended  review  of  this  truly 
remarkable  work  must  be  apparent.  We  have  not  a 
single  fault  to  find  with  it,  and  most  heartily  com- 
meud  it  to  the  careful  study  of  every  physician  who 
would  not  only  always  he  sure  of  his  diagnosis  of 
yregnaucy,  but  always  ready  to  treat  all  the  nume- 
rous ailments  that  are,  unfortunately  for  the  civilized 
women  of  to-day,  so  commonly  associated  with  the 
function.— JV.  1'.  Med.  Record,  March  16,  1868. 

We  have  much  pleasure  ii^  calling  the  attention  of 
our  readers  to  the  volume  produced  by  Dr.  Tanner, 
the  second  edition  of  a  work  that  was,  in  its  original 


state  even,  acceptable  to  the  profession.  We  recom- 
mend obstetrical  students,  young  and  old,  to  have 
this  volume  in  tlieir  collections.  It  contains  not  only 
a  fair  statement  of  the  signs,  symptoms,  and  diseases 
of  pregnancy,  but  comprises  in  addition  much  inter- 
esting relative  matter  that  is  not  to  be  found  in  any 
other  work  that  we  can  name. — Edinburgh  Med. 
Journal,  Jan.  1868. 

In  its  treatment  of  the  signs  and  diseases  of  preg- 
nancy it  is  the  most  complete  book  we  know  of, 
abounding  on  every  page  with  matter  valuable  to  the 
general  practitioner. — Cincinnati  Med.  Repertory, 
March,  1868. 

This  is  a  most  excellent  work,  and  should  be  on  the 
table  or  in  the  library  of  every  practitioner. — Hum- 
boldt Med.  Archives,  Feb.  1868. 

A  valuable  compendium,  enriched  by  his  own  la- 
bors, of  all  that  is  known  on  the  sigus  and  diseases  of 
pregnancy. — tit.  Uouis  Med.  Reporter,  Feb.  15,  IStiS. 


M' 


ONTGOMERT  [W.  F.),  M.D., 

Professor  of  Midwifery  in  tite  King's  and  Queen's  College  of  Physicians  in  Ireland. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREG- 

NANCY.  With  some  other  Papers  on  Subjects  connected  with  Midwifery.  From  the  second 
and  enlarged  Engli.sh  edition.  With  two  exquisite  colored  plates,  and  numerous  wood-cuta 
In  one  very  }iandsom'e  octavo  volume  of  nearly  600  pages,  extra  cloth.     $3  75. 


JiflLLER  {HENRY),  M.D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c.;  including 

the  Treatment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered 
as  a  frequent  cause  of  Abortion.  With  about  one  hundred  illustrations  on  wood.  In  od« 
very  handsome  octavo  volume  of  over  600  pages,  extra  cloth.     $3  75. 


RIGBY'S  SYSTEM  OF  MIDWIFERY.  With  Notes 
and  Additional  Illustrations.  Second  American 
edition.  One  volume  octavo,  extra  cloth,  422  pages. 
$2oO. 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF  MID- 
WIFERY. Twelfth  edition,  with  the  author's  last 
improvements  and  corrections.  In  one  octavo  voV 
ume,  extra  cloth,  of  600  pages.    $3  50. 


Henry  C.  Lea's  Publications — {Midwifery). 


26 


lifEIGS  [CHARLES  D.),  31. D., 

•iJ*-  Lately  Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS:    THE    SCIENCE   AND   THE    ART.     Fifth   edition, 

revised.     With  one  hundred  and  thirty  illustrations.     In  one  beautifully  printed  octavo 
volume  of  760  large  pages.     Extra  cloth,  $5  50;  leather,  $6  50.      {Just  Issued.) 

The  original  edition  is  already  so  extensively  and    practitioner.   1'he  rapidity  with  which  the  very  large 

editions  have  been  exliausted  is  the  best  test  of  its 
true  merit  Besides,  it  is  the  production  of  an  Ame- 
rican who  has  probably  had  more  experience  in  this 
branch  than  any  other  living  practitioner  of  the  conn- 
try. — St.  Louis  Med.  and  Surg.  Journal,  Sept.  1867. 


favorably  known  to  the  jirofession  that  no  recom 
iiiendation  is  necessary;  it  is  sutflcient  to  say,  the 
present  edition  is  very  much  extended,  improved, 
and  perfected.  Whilst  the  great  practical  talents  and 
unlimited  experience  of  the  author  render  it  a  most 
valuable  acquisition  to  the  practitioner,  it  is  so  con- 
densed as  to  constitute  a  most  eligible  and  excellent 
text-book  for  the  student. — Southern  Med.  and  Surg. 
Journal,  July,  1867. 

It  is  to  the  student  that  our  author  has  more  par- 
ticularly addressed  himself;  but  to  the  practitioner 
we  believe  it  would  be  equally  serviceable  as  a  book 
of  reference.  No  work  that  we  have  met  with  so 
thoroughly  details  everything  that  falls  to  the  lot  of 
the  accoucheur  to  perform.  Every  detail,  no  matter 
how  minute  or  how  trivial,  has  found  a  place. — 
Canada  Med  teal  Journal,  July,  1867. 

This  very  excellent  work  on  the  science  and  art  of 
otostetrics  should  be  in  the  hands  of  every  student  and 


He  has  also  carefully  endeavored  to  be  minute  and 
clear  in  his  details,  with  as  little  reiteration  as  possi- 
ble, and  beautifully  combines  the  relations  of  science 
to  art,  as  far  as  the  different  classifications  will  admU. 
— Detroit  Review  of  Med  and  Pharm.,  Aug.  1867. 

We  now  take  leave  of  Dr.  Meigs.  There  are  many 
other  and  interesting  points  in  his  book  on  which  WB 
would  fain  dwell,  but  are  constrained  to  bring  our  ob- 
servations to  a  close.  We  again  heartily  express  our 
approbation  of  tho  labors  of  Dr.  Meigs,  extending  over 
many  years,  and  culminating  in  the  work  before  us, 
full  of  practical  hints  for  the  inexperienced,  and  even 
for  those  whose  experience  has  been  considerable. — 
Glasgow  Medical  Journal,  Sept.  1867. 


T)AMSBOTHAM  {FRANCIS  H.),  M.D. 


THE    PRINCIPLES   AND    PRACTICE   OF    OBSTETRIC    MEDI- 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  test,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 

To  the  physician's  library  it  is  indispensable,  while 
to  the  student,  as  a  text-book,  from  which  to  extract 
the  material  for  laying  the  foundation  of  an  education 
on  obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

When  we  call  to  mind  the  toil  we  underwent  in 
acquiring  a  knowledge  of  this  subject,  we  cannot  but 
envy  the  student  of  the  present  day  the  aid  which 
this  work  will  afford  him. — Am.  Jour,  of  tlte  JUed. 
Sciences. 


We  will  only  add  that  the  student  will  learn  from 
it  all  he  need  to  know,  and  the  practitioner  will  find 
it,  as  a  book  of  reference,  surpassed  by  none  other. — 
Stethoscope. 

The  character  and  merits  of  Dr.  Ramsbotham'a 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous. 
The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.  We  cannot 
too  highly  recommend  the  work  to  our  readers. — St. 
Louis  Med.  and  Surg.  Journal. 


rjHURCHILL  [FLEETWOOD),  M.J).,  M.R.LA. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.     With  notes  and  additions 
by  D.  Francis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  .Diseases  of  Chil- 
dren,'' Ac.     With  one  hundred  and  ninety-four  illustrations.     In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Extra  cloth,  $4  00;  leather,  $6  00. 
In  adapting  this  standard  favorite  to  the  wants  of  the  profession  in  the  United  States,  the  editor 
has  endeavored  to  insert  everything  that  his  experience  has  shown  him  would  be  desirable  for  the 
American  student,  including  a  large  number  of  illustrations.     With  the  sanction  of  the  author, 
he  has  added,  in  the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwives  and 
Nurses,"  recently  issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  can  hardly 
fail  to  prove  of  advantage  to  the  junior  practitioner.     The  result  of  all  these  additions  is  that  the 
work  now  contains  fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one- 
half  more  illustrations ;  so  that,  notwithstanding  the  use  of  a  smaller  type,  the  volume  contains 
almost  two  hundred  pages  more  than  before. 


These  additions  render  the  work  still  more  com- 
plete and  acceptable  than  ever;  and  with  the  excel- 
lent style  in  which  the  publishers  have  presented 
this  edition  of  Churchill,  we  can  commend  it  to  the 
profession  with  great  cordiality  and  pleasure. — Cin- 
cinnati Lancet. 

Few  works  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  It,  whether  in  regard 
to  theory  or  practice,  and  in  one  respect  it  is  superior 
to  all  others,  viz.,  in  its  statistical  information,  and 
Uierefore,  on  these  grounds  a  most  valuable  work  for 
the  physician,  student,  or  lecturer,  all  of  whom  will 
find  in  it  the  information  which  they  are  seeking. — 
Brit.  Am.  Journal. 

The  present  treatise  is  very  ranch  enlarged  and 
aiuplitled  beyond  the  previous  editions  but  nothing 


has  been  added  which  could  be  well  dispensed  with. 
An  examination  of  the  table  of  contends  shows  how 
thoroughly  the  author  has  gone  over  the  ground,  and 
the  care  he  has  taken  in  the  text  to  present  the  sub- 
jects in  all  their  bearings,  will  render  this  new  edition 
even  more  necessary  to  the  obstetric  student  than 
were  either  of  the  former  editions  at  the  date  of  their 
appearance.  No  treatise  on  obstetrics  with  which  w« 
are  acquainted  can  compare  favorably  with  this,  in 
respect  to  the  amount  of  material  which  has  be«>n 
gathered  from  every  source. — Boston  Med.  and  Sung. 
Journal. 

There  Is  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practising  physician 
than  this.  It  should  adorn  and  enrich  evury  medicttl 
library. — Chicago  Med.  Jortrnal. 


26 


Henry  C.  Lea's  Publications — (Surgery). 


QROSS  {SAMUEL  D.),  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SURGERY:    Pathological,  Diagnostic,  Therapeutic, 

and  Operative.    Illustrated  by  upwards  of  Thirteen  Hundred  Engravings.    Fourth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  royal  octavo  volumes 
of  2200  pages,  strongly  bound  in  leather,  with  raised  bands.     $15  00. 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    Though 
but  little  over  six  years  have  elapsed  since  its  first  publication,  it  has  already  reached  its  fourth 
edition,  while  the  care  of  the  author  in  its  revision  and  correction  has  kept  it  in  a  constantly  im- 
proved shape.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.     This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding, 
renders  it  one  of  the  cheapest  works  accessible  to  the  profession.     Every  subject  properly  belonging 
to  the  domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be 
said  to  have  in  it  a  surgical  library. 


It  must  long  I'emain  the  most  comprehensive  work 
on  this  important  part  of  medicine. — Boston  Medical 
and  Surgical  Journal,  March  23,  1S6.5. 

We  have  compared  it  with  most  of  our  standard 
Works,  such  as  those  of  Erichsen,  Miller,  Fergusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
ftuihor,  award  it  the  pre-eminence.  As  a  work,  com- 
plete in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  erahracing  every  suhject  known  in 
the  principles  and  practice  of  surgery,  we  believe  it 
stands  without  a  rival.  Dr.  Gross,  in  his  preface,  re- 
marks "my  aim  has  been  to  embrace  the  whole  do- 
main of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;"  and,  we  assure  our 
readers,  he  has  kept  his  word.  It  is  a  work  which 
we  can  most  confldenlly  recommend  to  our  brethren, 
for  its  utility  is  becoming  the  more  evident  the  longer 
it  is  upon  the  shelves  of  our  library. — Canada  Med. 
Journal,  September,  186.5. 

The  first  two  editions  of  Professor  Gross'  System  of 
Surgery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  that  it  would  be  idle  for  us  to  speak  in 
praise  of  this  work. —  Chicago  Medical  Journal, 
September,  1865. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  which 
we  made  when  noticing  its  first  appearance. — British 
and  Foreign'MKdico-Chirurgical  Ri-view,  Oct.  IStiu. 

The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a  commanding  position  in  our  surgical  litera- 
ture, and  he  the  crowning  glory  of  the  author's  well 
earned  fame.  As  an  authority  on  general  surgical 
subjects,  this  work  is  long  to  occupy  a  pre-eminent 
place,  not  only  at  home,  but  abroad.  We  have  no 
hesitation  in  pronouncing  it  without  a  rival  in  our 
language,  and  equal  to  the  best  systems  of  surgery  in 
any  language. — N.  Y.  Med.  Journal. 

Not  only  by  far  the  best  text-book  on  the  subject, 
SB  a  whole,  within  the  reach  of  American  students, 
but  one  which  will  he  much  more  than  ever  likely 
to  be  resorted  to  and  regarded  as  a  high  authority 
abroad. — Ara.  Journal  Med.  Sciences,  Jan.' 186.5. 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu- 
lations and  operations.  It  is  a  complete  Thesaurus 
of  modera  Burgery,  where  the  student  and  practi- 


tioner shall  not  seek  in  vain  for  what  they  desire.— 
San  Francisco  Med.  Press,  Jan.  186.5. 

Open  it  where  we  may,  we  find  sound  practical  in- 
formation conveyed  in  plain  language.  This  book  is 
no  mere  provincial  or  even  national  system  of  sur- 
gery, but  a  work  which,  while  very  largely  indebted 
to  the  past,  has  a  strong  claim  on  the  gratitude  of  th« 
future  of  surgical  science. — Edinhnrgh  Med.  Journal, 
Jan.  186,5. 

A  glance  at  the  work  is  sufficient  to  show  that  the 
author  and  publisher  have  spared  no  labor  in  making 
it  the  most  cuniplete  "System  of  Surgery"  ever  pub- 
lished in  any  ciinntry. — St.  Louis  Med.  and  Surg. 
Journal,  April,  186.5. 

The  third  opportunity  Is  now  offered  during  our 
editorial  life  to  review,  or  rather  to  indorse  and  re- 
commend this  great  American  work  on  Surgery. 
Upon  this  last  edition  a  great  amount  of  labor  has 
been  expended,  though  to  all  others  except  the  author 
the  work  was  regarded  in  its  previous  editions  as  so 
full  and  complete  as  to  be  hardly  capable  of  improve- 
ment. Every  chapter  has  been  revised;  the  text  aug- 
mented by  nearly  two  hundred  pages,  and  a  con- 
siderable number  of  wood-cuts  have  been  introduced. 
Many  portions  have  been  entirely  re-writteu,  and  the 
additions  made  to  the  text  are  principally  of  a  prac 
tical  character.  This  comprehensive  treatise  upon 
surgery  has  undergone  revisions  and  enlargements, 
keeping  pace  with  the  progress  of  the  art  and  science 
of  surgery,  so  that  whoever  is  in  possession  of  this 
work  may  consult  its  pages  upon  any  topic  embraced 
within  the  scope  of  its  department,  and  rest  satisfied 
that  its  teaching  is  fully  up  to  the  present  standard 
of  surgical  knowledge.  It  is  also  so  comprehensive 
that  it  may  truthfully  be  said  to  embrace  all  that  is 
actually  known,  that  is  really  of  any  value  in  the 
diagnosis  and  treatment  of  surgical  diseases  and  acci- 
dents. Wherever  illustration  will  add  clearness  to  the 
subject,  or  make  better  or  more  lasting  impression,  it 
is  not  wanting;  in  this  respect  the  work  is  eminently 
superior. — Buffalo  Med.  Journal,  Dec.  1864. 

A  system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelibly  associate  his 
name  with  surgical  science.  And  what,  in«our  opin- 
ion, enhances  the  value  of  the  work  is  that,  while  the 
practising  surgeon  will  find  all  that  he  requires  in  it, 
it  is  at  the  same  time  one  of  the  most  valuable  trea- 
tises which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  and  practice  of  this 
branch  of  the  profession  which  he  designs  subse- 
quently to  follow. — Tim  Brit.  Am.  Journ.,  Montreal. 


Ttr  THE  SAME  AUTHOR.  

A  PRACTICAL    TREATISE    ON   THE    DISEASES,   INJURIES, 

AND  MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND, 
AND  THE  URETHRA.  Second  edition,  revised  and  much  enlarged,  with  one  hundred 
and  eighty-four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nin« 
hundred  pages,  extra  cloth.     $4  00. 


Whoever  will  peruse  the  vast  amount  of  valuable 
practical  information  it  contains  will,  we  think,  agree 
with  us,  that  there  is  no  work  in  the  English  lan- 

nr  THE  SAME  AUTHOR.  — 

A   PRACTICAL 

AIR-PASSAGES. 

pp.  4S8.     $2  75. 


gnage  which  can  make  any  just  pretensions  to  be  its 
equal. — A\  1'.  Journal  of  Medicine. 


TREATISE    ON   FOREIGN    BODIES   IN  THE 

In  one  handsome  octave  volume,   extra  cloth,   with  illustrations. 


Henry  C.  Lea's  Publications — (Surgery).  21 

J^RICHSEN  {JOHN), 

•'-*  Professor  of  Surgery  in  Univursity  College,  London. 

THE  SCIENCE  AND  ART  OF  SURGERY;  beincr  a  Treatise  on  Sur- 

gical  Injuries,  Diseases,  and  Operations.  New  and  improved  American,  from  the  Second 
enlarged  and  carefully  revised  London  edition.  Illustrated  with  over  four  hundred  wood 
engravings.  In  one  large  and  handsome  octavo  volume  of  1000  closely  printed  pages ;  extra 
cloth,  $6;  leather,  raised  bands,  $7. 

We  are  hound  to  state,  and  we  do  so  without  wish-  I  as  one  of  the  very  best,  if  not  the  best  text-book  of 
ing  to  draw  iuvidious  comparisons,  that  the  work  of!  surgery  with  which  we  were  acquainted,  permits  ns 
Mr.  Ericlisen,  in  most  respects,  surpasses  any  that  to  give  it  but  a  passing  notice  totally  unworthy  of  its 
has  preceded  it.  Mr.  Erichsen's  is  a  practical  work,  \  merits.  It  may  be  confidently  asserted,  that  no  work 
combining  a  due  proportion  of  the  "Science  and  Art  on  the  science  and  art  of  surgery  has  ever  received 
of  Surgery."  Having  derived  no  little  instruction  more  universal  commendation  or  occupied  a  higlier 
from  it,  in  many  important  branches  of  surgery,  we  position  as  a  general  text-book  on  surgery,  than  this 
can  have  no  hesitation  in  recommending  it  as  a  valu-  treatise  of  Professor  Erichsen. — Savannah  Journal  of 
able  book  alike  to  the  practitioner  and  the  student.  [  Medicine. 
—  Dublin  Quarterly.  j      in  fulness  of  practical  detail  and  perspicuity  of 

Oivfcs  a  very  admirable  practical  view  of  the  scl-  style,  convenience  of  arrangement  and  soundness  of 
e«ce  and  art  of  surgery. — Edinburgh  Med.  and  Surg,  discrimination,  as  well  as  fairness  and  comi)letenes8 
Journal.  1  of  discussion,  it  is  better  .suited  to  tlie  wants  of  both 

We  recommend  it  as  the  best  compendium  of  sur-  fitudont  and  practitioner  than  any  of  its  predecessors, 
gery  in  our  language.-io7!,ioji  Lancet.  ;  --■»"»•  '^^>v^rnal  of  Med.  Sciences. 

It  is,  we  think,  the  most  valuable  practical  work  '  After  careful  and  frequent  perusals  of  Erichsen's 
on  surgery  in  existence,  both  for  voang  and  old  prac-  .  f.^rger/..  ^e  are  at  a  lo.ss  fully  to  express  our  a.  inira- 
KXthm^TS.-Nashoille  Med.  and  Surg.  Journal.  \  »>»"  "f ''■    ^ho  author  s  style  is  eminently  didactic, 

I  and  characterized  by  a  most  admirable  directness. 

The  limited  time  we  have  to  review  this  improved  clearness,  and  compactness. — Ohio  Med.  and  Surg. 
edition  of  a  work,  the  first  issue  of  which  we  prized    Journal. 

r>T  THE  SAME  AUTBOR.     (Ready  in  June.) 

ON   RAILWAY,    AND    OTHER    INJURIES  .OF    THE    NERVOUS 

SYSTEM.     In  small  octavo  volume.     Extra  cloth,  $1  00. 


We  welcome  this  as  perhaps  the  most  practically 
useful  treatise  written  for  many  a  day. — Medical 
Times. 

It  will  serve  as  a  most  useful  and  trustworthy  guide 


to  the  profession  in  general,  many  of  whom  may  l)e 
consulted  in  such  cases;  and  it  will,  no  doiilit,  lake 
its  place  as  a  text-book  on  the  subject  of  which  it 
treats. — Medical  Prexs. 


JlflLLER  [JAMES), 

J-'-L  Late  Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and 

revised  Edinburgh  edition.     In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  extra  cloth.     $3  75. 

r  THE  SAME  AUTHOR.  


B 

THE    PRACTICE    OF   SURGERY.     Fourth  American,  from  the  la.st 

Edinburgh  edition.     Revised  by  the  American  editor.     Illustrated  by  three  hundred  and 

sixty-four  engravings  on  wood.     In  one  large  octavo  volume  of  nearly  700  pages,  extra 

cloth.     $3  75. 

It  ts  seldom  that  two  volumes  have  ever  made  so  I  acquired.    The  author  is  an  eminently  sensible,  prao- 

profound  an  impression   in  so   sliort  a  time   as  the     tical,  and  wcll-infornied   man,   who    knows  exiiitly 

"Principles"  and  the  "  Practice"  of  Surgery  by  Mr.     what  he  is  talking  about  and  exactly  how  to  talk  it. — 

Miller,  or  .so  richly  merited  the  reputation  they  have  |  Kentucky  Medical  Recorder. 


P 


IRRIE  ( WILLIAM),  F.  R.  S.  E.. 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by 

John  Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  Ac.  In  one  very  handsome  octavo  volume  of  780  pages,  with  316 
illustrations,  extra  cloth.     $3  75. 


iJARGENT  {F.  W.),  M.  D. 


ON  BANDAQING  AND  OTHER  OPERATIONS  OF  MINOR  SUR- 

GERY.    New  edition,  with  an  additional  chapter  on  Military  Surgery.    One  handsome  royaJ 

12mo.  volume,  of  nearly  400  pages,  with  184  wood-cuts.     Extra  cloth,  $1  75. 

Exceeilingly  convenient  and  valuable  to  all  mora-        We  cordially  commend  this  vuluuio  as  one  wliloli 

b^Ts  of  the  profession.— CTiicaj^o  Mtdical  Examiner,     the  ineilical  student  should  most  closely  study;  and 

May,  ISii'J.  to  the  surgeon  in  practice  it  must  prove  Itself  iustrne*- 

The  'very  best  manual  of  Minor  Surgery  we  have    '/^  on  many  points  which  he  may  have  forgolleu<— 

»eea.— Buffalo  Medical  Journal.  ^rit.  Am.  Journal,  May.  ISiii 


MALGAIGNE'S  OPERATIVE  SDRQERT.  With  nn-  I  SKEY'S  0PER.4TIVE  SHKOERT.  In  ome  very  hand> 
nierous  illustrations  on  wood.  In  one  handsome  some  octavo  volume,  extra  cloth,  of  over  e.'M)  pagoa, 
o«tavo  volume,  extra  cloth,  of  nearly  600  pp.    l|2  60.  |      with  about  100  wood-cau.    $3  26. 


28 


Henry  C.  Lea's  Publications — (Surgery). 


TiRUITT  {ROBERT),  M.R.C.S.,  Sfc. 


THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated veith  four  hundred  and  thirty -two  wood-engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages.    Extra  cloth,  $4  00  ;  leather,  $5  00. 

Besides  the  careful  revision  of  the  author,  this  work  has  had  the  advantage  of  very  thorough 
editing  on  the  part  of  a  competent  surgeon  to  adapt  it  more  completely  to  the  wants  of  the  Ameri- 
can student  and  practitioner.  Many  illustrations  have  been  introduced,  and  every  care  has  been 
taken  to  render  the  mechanical  execution  unexceptionable.  At  the  very  low  price  afiBxed,  it  will 
tiierefore  be  found  one  of  the  most  attractive  and  useful  volumes  accessible  to  the  American 
practitioner. 

All  that  the  surgical  student  or  practitioner  could  i  theoretical  surgical  opinions,  no  work  that  we  are  at 


desire. — Duhlin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston,  Med.  and  Surg.  Journal. 

In  Mr.  Druitt's  book,  though  containing  only  some 
seven  hundred  pages,  both   the   principles  and  the 


present  acquainted  with  can  at  all  compare  with  it. 
It  is  a  compendium  of  surgical  theory  (if  we  may  use 
the  word)  and  practice  in  itself,  and  well  deserves 
the  estimate  placed  upon  it. — Brit.  Am.  Journal. 

Thus  enlarged  and  improved,  it  will  continue  to 
rank  among  our  best  text-books  on  elementary  su?- 


praclice  of  surgery  are  treated,  and  so  clearly  and  ^exy.-Columhux  Rev.  of  Med.  and  Surg. 
perspicuously,  as  to  elucidate  every  important  topic.  |  We  must  close  this  brief  notice  of  an  admirable 
Thefactthat'twelve  editions  have  already  been  called  i  work  by  recommending  it  to  the  earnest  attention  of 
for,  in  these  days  of  active  competition,  would  of  every  medical  student. — Charleston  Medical  Journal 
itself  show  it  to  possess  marked   superiority.     We    and  Review. 

have  examined  the  book  most  thoroughly,  and  can  I  ^  text-book  which  the  general  voice  of  the  profes- 
say  that  this  success  is  well  merited.  His  book,  ^j^j  j^  both  England  and  America  has  commended  as 
moreover,  possesses  the  inestimable  advantages  of  ^^^  ^f  ^^^  j„„st  admirable  "manuals,"  or,  "wtcJ* 
having  the  subjects  perfectly  well  arranged  and  clas-  „j,,g„^>.  ^^  ■^^^  English  title  runs,  which  can  b« 
siHed,  and  of  being  written  in  a  style  at  once  clear  pi„ced  in  the  hands  of  the  student.  The  merits  of 
and  succinct.— ^m.  Journal  of  Med.  Sciences.  Druitt's  Surgery  arc  too  well  known  to  every  one  to 

Whether  we  view  Druitt's  Surgery  as  a  guide  to    need  any  further  eulogium  from  us. — Nashville  Med. 
operative  procedures,  or  as  representing  the  latest    Journal. 


H 


AMILTON  [FRANK  H.),  M.D., 

Professor  of  Fractures  and  I>islocations,  &c.  in  Bellevue  Hasp.  Med.  College,  New  York. 

A  PRACTICAL  TREATISE   ON  FRACTURES  AND   DISLOCA- 

TIONS.     Third  edition,  thoroughly  revised.     In  one  large  and  handsome   octavo  volume 
of  777  pages,  with  294  illustrations,  extra  cloth,  $5  75.     (Just  Issteed.) 

The  demand  which  has  so  speedily  exhausted  two  large  editions  of  this  work  shows  that  the 
author  has  succeeded  in  supplying  a  want,  felt  by  the  profession  at  large,  of  an  exhaustive  treatise 
on  a  frequent  and  troublesome  class  of  accidents.  The  unanimous  voice  of  the  profession,  abroad 
as  well  as  at  home,  has  pronounced  it  the  most  complete  work- to  which  the  surgeon  can  refer  for 
information  respecting  all  details  of  the  subject.  In  the  preparation  of  this  new  edition,  the 
author  has  sedulously  endeavored  to  render  it  worthy  a  continuance  of  the  favor  which  has  been 
accorded  to  it,  and  the  experience  of  the  recent  war  has  afforded  a  large  amount  of  material  which 
he  has  sought  to  turn  to  the  best  practical  account. 

In  fulness  of  detail,  simplicity  of  arrangement,  and  ;  American  professor  of  surgery;  and  his  book  adds 
accuracy  of  description,  this  work  stands  unrivalled,  jone  more  to  the  list  of  excellent  practical  works  which 
So  far  as  we  know,  no  other  work  on  the  subject  in  '  have  emanated  from  his  country,  notices  of  which 
the  English  language  can  be  compared  with  it.  While  have  appeared  from  time  to  time  in  our  columns  du- 
congratulating  our  trans-Atlantic  brethren  on  the!  ring  the  last  few  months.— iondon  Zanee<,  Dec.  15, 
European  reputation  which  Dr.  Hamilton,  along  with    1866. 

many  other  American  surgeons,  has  attained,  we  also  1  Tiiese  additions  make  the  work  much  more  valua- 
may  be  proud  that,  in  the  mother  tongue,  a  classical  i  ble,  and  it  must  be  accepted  as  the  most  complete 
work  has  been  produced  which  need  not  fear  compa- '  monograph  on  the  subject,  certainly  in  our  own,  if 


rison  with  the  standard  treatises  of  any  other  nation. 
— Edinburgh  Med.  Journal,  Dec.  1860. 

The  credit  of  giving  to  the  profession  the  only  com 


not  even  in  any  other  \».a^\xa,gQ.  — Am.erican  Journal 
Med.  Sciences,  Jan.  1867. 
This  is  the  most  complete  treatise  on  the  subject  in 


The  credit  ol  giving  to  tne  proiession  me  oniy  com     .,  * "      , .  'r, d      i  •      r"^i,  7      ,   t    "^  ic^i 

plete  practical  treatise  on  fractures  and  dislocations  /^^e  English  \a.^^yia.g6.- Ranking  s  Abstract,  Jan.  im. 
in  our  language  during  the  present  century,  belongs  A  mirror  of  all  that  is  valuable  in  modern  surgery, 
to  the  author  of  the  work  before  us,  a  distinguished  Richmond  Med.  Journal,  Nov.  1866, 


BRODIE'S  CLINICAL  LECTURES  ON  SURGERY. 
1  vol.  8vo.,  3oO  pp.;  cloth,  %\  25. 

BARWELLS  TREATISE  ON  DISEASES  OF  THE 
JOINTS.  With  illustrations.  1  vol.  8vo.,  of  about 
600  pages  ;  extra  cloth,  $.3  00. 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
rRACTiCE  OF  Surgery.  In  one  very  large  octavo 
volume,  extra  cloth,  of  750  pages.    $2  00. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
OERV.  Eighth  edition,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pages,  leather,  raised  bands.  $6  50 

JOKES'   PRINCIPLliS   AND    PRACTICE   OF  OPH- 


THALMIC MEDICINE  AND  SURGERY.  With  one 
hundred  and  seventeen  illustrations.  Third  and 
revised  Americam,  with  Additions  from  the  second 
London  edition.  In  one  handsome  octavo  volumre 
of  45.T  pages,  extra  cloth.  $3  2.5. 
MACKENZIE'S  PRACTICAL  TREATISE  ON  DI8J 
EASES  AND  INJURIES  OF  THE  EYE.  Brom  the 
fourth  revised  and  enlarged  London  edition.  With 
Notes  and  Additions  by  Addinell  Hewson,  M  D., 
Surgeon  to  Wills  Hospital,  &c.  &c.  In  one  very 
large  and  handsome  octavo  volume  of  1027  pages.^ 
extra  cloth,  with  plates  and  numerous  woodcnte. 
SSU  50. 


Henry  C.  Lea's  Publications — (Surgery). 


29 


rpOYNBEE  {JOSEPH),  F.  R.  S., 

-*-  Aural  Surgeon  to  and  Lecturer  on  Surgery  at  St.  Mnrifs  Hospital. 

THE  DISEASES  OF  THE  EAR:  their  Nature,  Diagnosis,  and  Treat- 
ment. With  one  hundred  engravings  on  wood.  Second  American  edition.  In  one  very 
handsomely  printed  octavo  volume  of  440  pages;  extra  cloth,  $4.  ^ 


The  appearance  of  a  volume  of  Mr.  Toynbee's,  there- 
fore, ia  which  the  subject  of  aural  disease  is  treated 
In  the  most  scientific  manner,  and  our  knowledge  in 
respect  to  it  placed  fully  on  a  par  with  that  which 
we  possess  respecting  most  other  organs  of  the  body, 
is  a  matter  for  sincere  congratulation.  We  may  rea- 
sonably hope  that  henceforth  the  subject  of  this  trea- 
tise will  cease  to  be  among  the  opprol/ria  of  medical 
science. — London  Medical  Review. 


The  work,  as  was  stated  at  the  ontset  o'our  notice, 
is  a  model  of  its  kind,  and  every  page  and  paragraph 
of  it  are  worthy  of  the  most  thorough  study.  Con- 
sidered all  in  all — as  an  original  work,  well  written, 
philosophically  elaborated,  and  happily  illustrated 
with  cases  and  drawings — it  is  by  far  the  ablest  mo- 
nograph that  has  ever  appeared  on  the  anatomy  and 
diseases  of  the  ear,  and  one  of  the  most  valuable  con- 
tributions to  the  art  and  science  of  .surgery  in  the 
nineteenth  century. — N.  Am.  Med.-Vliirurg.  Revieto. 


T  A  URENCE  [JOHN  Z.),  F.  R.  C.  S.,    and      MOON  [ROBERT  C), 

-^  EdUor  of  the  Ophthalmic  Review,  &e.  -'■"■      -»■''«««  S^irgeon  to  theSoulhwark  Oph- 

thalmic  Ho,spital,  &c. 

A  HANDY-BOOK  OF   OPHTHALMIC   SURGERY,  for  the  use  of 

Practitioners.     With  numerous  illustrations.     In  one  very  handsome  octavo  volume,  extra 
cloth.     $2  50.     (Just  Issued.) 

Not  only,  as  its  modest  title  suggests,  a  "Handy- 
Book"  of  Ophthalmic  Surgery,  but  an  excellent  and 
well-digested  rimiint  of  all  that  is  of  practical  value 
in  the  specialty. — New  York  Medical  Journal,  No- 
vember, 1S66. 


No  book  on  ophthalmic  surgery  was  more  needed. 
Designed,  as  it  is,  for  the  wants  of  the  busy  practi- 
tioner, it  is  the  neplus  ultra,  of  perfection.  It  epito- 
Bttizes  all  the  diseases  incidental  to  the  eye  in  a  clear 
and  masterly  manner,  not  only  enabling  the  practi- 
tioner readily  to  diagnose  each  variety  of  disease,  but 
affording  him  the  more  imporiant  assistance  of  proper 
treatment.  Altogether  this  is  a  work  which  ought 
certainly  to  be  in  the  hands  of  every  general  practi- 
tioner.— Dublin  Med.  Press  and  Circular,  Sept.  12,  '66. 

We  cordially  recommend  this  book  to  the  notice  of 
our  readers,  as  containing  an  excellent  outline  of 
modern  ophthalmic  surgery. — British  Med.  Journal, 
October  13,  1866. 


This  object  the  authors  have  accomplished  in  a 
highly  satisfactory  manner,  and  we  know  no  work 
we  can  more  highly  recommend  to  the  "busy  practi- 
tioner" who  wishes  to  make  himself  acquainted  with 
the  recent  improvements  in  ophthalmic  science.  Such, 
a  work  as  this  was  much  wanted  at  this  time,  and 
this  want  Messrs.  Laurence  and  Moon  have  now  well 
supplied. — Am.  Journal  Med.  Sciences,  Jan.  1S67. 


TA  W80N  [GEORGE),  F.  R.  G.  S.,  Engl 

-*-'  Asstitant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Moorfw.ld.i,  &c. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 

diate  and  Remote  Effects.  With  about  one  hundred  illustrations.  In  one  very  hand- 
some octavo  volume,  extra  cloth,  $3  50.      (Now  Ready.) 

This  work  will  be  found  eminently  fitted  for  the  general  practitioner.  In  cases  of  functional 
or  structural  diseases  of  the  eye,  the  physician  who  has  not  made  ophthalmic  surgery  a  special 
study  can,  in  most  instances,  refer  a  patient  to  some  competent  practitioner.  Cases  of  injury, 
however,  supervene  suddenly  and  usually  require  prompt  assistance,  and  a  work  devoted  espe- 
cially to  them  cannot  but  prove  essentially  useful  to  those  who  may  at  any  moment  be  called  upon 
to  treat  such  accidents.  The  present  volume,  as  the  work  of  a  gentleman  of  large  experience, 
may  be  considered  as  eminently  worthy  of  confidence  for  reference  in  all  such  emergencies. 

It  is  an  admirable  practical  book  in  the  highest  and    fulness  of  practical  knowledge.     We  predict  for  Mr. 


best  sense  of  the  phrase.  Copiously  illustrated  by 
excellent  woodcuts,  and  with  well-selecled,  well- 
described  cases,  it  is  written  in  plain,  simple  lan- 
guage, and  in  a  style  the  transparent  clearness  and 
Frankness,  so  to  speak,  of  which,  add  greatly  to  its 
value  and  usefulness.  Only  a  master  of  his  subject 
could  so  write;  every  topic  is  handled  with  an  ease, 
decision,  and  straightforwardness,  that  show  the 
skilful  and   highly  educated   surgeon  writing  from 


Lawson's  work  a  great  and  well-merited  success. 
We  are  confident  that  the  profession,  and  especially, 
as  we  have  said,  our  country  brethren,  will  feel 
grateful  to  him  for  having  given  them  in  it  a  guide 
and  counsellor  fully  up  to  the  most  advanced  state  of 
Ophthalmic  Surgery,  and  of  whom  they  can  make  a 
trusty  and  familiar  friend. — London  Mulical  Timee 
and  Oazette,  May  18,  1867. 


irORLAND  [W.  W.),  M.D. 


DISEASES  OF  THE  URINARY  ORGANS;  a  Compendium  of  their 

Diagnosis,  Pathology,  and  Treatment.     With  illustrations.     In  one  large  and  handsome 
octavo  volume  of  about  600  pages,  extra  cloth.     $3  50. 
Taken  as  a  whole,  we  can  recommend  Dr.  Morlnnd'n  I  of  every  medical  or  surgical  praciilioBer. — Brit,  and 
eompendinmasa very  deslrableadditJouto thelibrary  |  Fiir.  Med.-Chir.  Revieto,  April,  1869. 


riURUNG  {T.B.),  F.R.S., 

Surgeiin  to  the  London  Hospital,  President  of  thf  Hunterinn  Society,  *c. 

A  PRACTICAL   TREATLSR   ON   DISEASES   OF   THE   TESTIS, 

SPERMATIC  CORD,  AND  SCROTUM.  Seoond  American,  from  the  second  and  enlarged 
Enelish  edition.  In  one  handaome  octavo  volume,  extra  cloth,  with  numerous  illustra- 
tions,    pp.  420.     $2  00. 


30 


Henry  C.  Lea's  Publications — (Surgery). 


rmLES  {PHILIP  S.),  M.  D.,  Surgeon  U.  S.  N. 


MECHANICAL  THERAPEUTICS:  a  Practical  Treatise  on  Surgical 

Apparatus,  Appliances,  and  Elementary  Operations  :  embracing  Minor  Surgery,  Band- 
aging, Orthopraxy,  and  the  Treatment  of  Fractures  and  Dislocations.  With  six  hundred 
and  forty-two  illustrations  on  wood.  In  one  large  and  handsome  octavo  volume  of  about 
700  pages:  extra  cloth,  $5  75;  leather,  $6  75.      {Now  Ready.) 

A  Naval  Medical  Board  directed  to  examine  and  report  upon  the  merits  of  this  volume,  oflScially 
states  that  "  it  should  in  our  opinion  become  a  standard  work  in  the  hands  of  every  naval  sur- 
geon ;"  and  its  adoption  for  use  in  both  the  Army  and  Navy  of  the  United  Slates  is  sufficient 
guarantee  of  its  adaptation  to  the  needs  of  every-day  practice. 


The  title  of  this  book  will  give  a  reasonably  good 
idea  of  its  .scope,  but  its  merits  can  only  be  appreci- 
ated by  a  careful  perusal  of  its  text.  No  one  who  un- 
dertakes such  a  task  will  have  any  reason  to  com- 
plain that  the  author  has  not  performed  his  duty,  and 
lias  not  taken  every  pains  to  present  every  subject  in 
A  clear,  common-sense,  and  practical  light.  It  is  a 
unique  specimen  of  literature  in  its  way,  in  that, 
treating  upon  such  a  variety  of  subjects,  it  is  as  a, 
whole  so  completely  up  to  the  wants  of  the  studeiit 
and  the  general  practitioner.  We  have  never  seen 
any  work  of  its  kind  that  can  compete  with  it  in  real 
utility  and  extensive  adaptability.  Dr.  Wales  per- 
fectly understands  what  may  naturally  be  required 
of  him  in  the  premi.ses,  and  !n  the  work  before  us  has 
bridged  over  a  very  wide  gap  which  has  always  here- 
tofore existed  between  the  lirst  rudiments  of  surgery 
and  practical  surgery  proper.  He  has  emphatically 
given  US  a  comprehensive  work  fur  the  beginner  ;  and 
when  wo  say  of  his  labors,  that  in  their  particular 
sphere  th(>y  leave  nothing  to  be  desired,  we  assert  a 
great  deal  to  recommend  the  book  to  the  attHnlion  of 
tiiose  specially  concerned.  In  conclusion,  we  woubl 
iitato,  at  the  risk  of  reileratiim,  that  this  is  the  most 
compreheusiveb.>okon  the  subj.^ct  that  we  have  seen  ; 
in  the  best  that  can  be  placed  in  the  hands  of  the  stu- 
dent in  need  of  a  first  book  on  snrgery,  and  the  most 
useful  that  can  be  named  for  such  general  practition- 
ers who,  without  any  special  pretensions  to  surgery, 
a^  occasionally  liable  to  treat  surgical  cases. — 2v.  1'. 
ited.  Record,  March  2,  1868. 

It  is  certainly  the  most  complete  and  thorough  work 
o^  its  kind  in  the  English  language.  Students  and 
young  practitioners  of  surgery  will  tind  it  invaluable. 
It  will  prove  especially  useful  to  inexperienced  coun- 
try practitioners,  who  are  continually  required  to 
t»ke  charge  of  surgical  cases,  under  circumstances 
precluding  them  from  the  aid  of  experienced  surgeons. 
— Pacific  Med.  and  Surg.  Journal,  Feb   186S. 

This  is  a  most  complete  and  elegant  work  of  67.3 
]>«ges,  and  is  certainly  woU  deserving  of  the  com- 
mendation of  every  Amorican  suriieou.  This  work, 
besides  its  usefulness  as  a  reference  for  practitioners, 
is  most  admirably  adapted  as  a  text-book  for  students. 
Its6^2illustratiou8in  woi)d-ciits,  represent  every  man- 
ner of  surgical  appliance,  together  with  a  minute  de- 
scription of  each,  the  name  of  its  inventor,  and  its  prac- 
tical utility  in  mechanical  surgery.  There  is,  perhaps, 
no  work  in  the  English  language  so  complete  in  the 
description  and  detail  of  surgical  apparatus  and  ap- 
pliances as  this  one.  The  entire  work  entitles  the  au- 
thor to  great  credit  for  his  clear  and  distinct  style  as 
a  writer,  as  well  as  for  his  accuracy  of  observation 
and  great  research  in  the  field  of  surgery.  We  ear- 
nestly recommend  every  member  of  the  profession  to 
add  a  cipy  of  it  to  his  library,  with  the  assurance 
that  he  will  find  some  useful  suggestion  in  the  treat- 
ment of  almost  every  surgical  case  that  may  come 
under  his  observation. — Humboldt  JItd.  Archives, 
Fei>.  1858. 


It  is  the  completestbook  on  these  subjects  we  know 
of,  and  it  cannot  fail  to  be  exceedingly  useful  to  the 
busy  practitioner,  especially  to  the  busy  country  phy- 
sician who  has  thrown  upon  his  care  something  of 
surgery  in  its  various  details,  with  all  manner  of  gene- 
ral practice,  and,  therefore,  may  often  wish  to  refresh 
himself  as  to  the  most  convenient  and  elegant  modes 
of  dressings  and  manipulations. — Cincinnati  Lancet 
and  Ohse.rmr,  Jan.  18>i8. 

We  have  examined  Dr.  Wales'  book  with  much 
care,  and  believe  that  his  labor  will  greatly  benefit 
the  practitioner  of  surgery.  It  seems  to  us  especially 
beneficial  to  the  country  medical  practitioner  who  is 
surgeon,  physician,  and  cibsteti'ician,  as  occasion  re- 
quires. We  commend  the  work  to  our  readers  as  a 
most  useful  one. — Nashville  Mtd.  and  Surg.  Journal, 
Jan.  1868. 

The  title  of  the  above  work  is  sufllciently  indica- 
tive of  its  contents.  We  have  not  seen  for  a  long 
time  (in  the  English  langnajfe)  a  treatise  equal  to  tluN 
in  extent,  nor  one  which  is  better  adapted  to  the 
wants  of  the  general  student  and  practitioner.  It  is 
not  to  the  surgeon  alone  that  this  book  belongs;  the 
physician  has  frequent  opportunities  to  fill  an  emer- 
gency by  such  knowledge  as  is  here  given.  Every 
practitioner  should  make  purchase  of  such  a  book — 
it  will  last  him  his  lifetime. — St.  Louis  Med.  S«- 
porttv,  Feb.  1868. 

A  useful  book  is  always  a  necessary  one,  and  that 
this  book  is  eminently  one  of  that  character,  needs 
but  a  glance  at  its  pages  to  show.  It  certainly  de- 
serves a  place  In  the  library  of  every  physician. — 
Leavenworth  Med.  Herald,  Feb.  186S. 

The  book  seems  to  be  complete  In  every  respect, 
and  is  a  welcome  addition  to  onr  shelves. — Boston 
Mtd   and  Surg.  Journal,  Jan.  9,  1868. 

In  onr  opinion  it  is  a  good  book,  and  one  which 
every  student  and  practitioner  needs  in  his  library. 
Especially  would  its  value  be  appreciated  by  the  sur- 
geon whose  field  of  practice  is  anywise  remote  from 
the  larger  cities. — Chicago  Med.  Journal,  Jan.  1868. 

This  volume  will  be  a  useful  acquisition  to  a  large 
number  of  the  working  members  of  the  medical  pro- 
fession in  thiscounlry.  I'ractitiouers  will  find  mate- 
rial aid  and  encouragement  in  its  pages  which  they 
could  nowhere  else  obtain,  to  the  same  extent,  in  sfl 
convenient  a  form. — Ant.  Journal  Med.  Sciences, 
Jan.  1868. 

He  must  be  a  blockhead  indeed  who,  after  study- 
ing this  portion  of  the  book  before  us,  fails  to  adapt 
himself  to  the  emergency  of  any  case,  for  we  find 
here  described  pretty  much  every  contrivance  ever 
devised,  and  we  can  hardly  conceive  of  Ihiit  combi- 
nation of  circumstances  wliicli  would  deprive  us  of 
all  these  means  of  assistance,  and  the  ab.seuce  of  on« 
or  more  of  the  usual  aids  would  only  stimulate  the 
ingenuity  to  devise  some  other  plan  of  relief. — Net* 
York  Med.  Journal,  May,  1868. 


A  SET  ON  [T.  J.) 
OX  THE   DISEASES,  INJURIES,  AND  MALFORMATIONS   OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  300  pages,     %'i  25.     {Just  Issued.) 


We  can  recommend  this  volume  of  Mr  Ashton's  in 
tbe  strongest  terms,  as  containing  all  the  latest  details 
at  the  pathology  and  treatment  of  diseases  connected 
with  the  rectum. — Canada  Med.  Journ.,  March,  1866. 

One  of  the  most  valuable  special  treatises  that  the 
physician  and  surgeon  can  have  in  his  library  — 
Chicago  Medical  ExanUner,  Jan.  1.S66. 


The  short  period  which  has  elapsed  since  the  ap- 
pearance of  the  former  -American  reprint,  and  th« 
numerous  editions  publir>hed  in  England,  are  the  best 
arguments  we  can  otfer  of  the  merits,  and  of  the  nse- 
lessness  of  any  commendation  on  oar  part  of  a  book 
already  so  favorably  known  to  our  readers. — Boston 
Med.  and  Surg.  Journal,  Jan.  26,  1866. 


Henry  C.  Lea's  Publications — {Medical  Jurisprudence^  &c.).     31 


rPAYLOR  {ALFRED  S.),  31.  D., 

-*-  Lecturer  on  Sled.  Jurisp.  and  Vhemiiilry  in  Guy's  Hospital. 

MEDICAL   JURISPRUDEXCE.     Sixth  American,  from   the   eighth 

and  revised  London  edition.     With  Notes  and  References  to  American  Decisions,  by  Cle- 
ment B.  Penrose,  of  the  Philadelphia  Bar.     In  one  large  octav^  volume  of  776  pages, 
extra  cloth,  $4  50  ;  leather,  $5  60.      {Just  Issued.) 
Considerable  additions  have  been  made  by  the  editor  to  this  edition,  comprising  some  important 
sections  from  the  author's  larger  work,  "  The  Principles  and  Practice  of  Medical  Jurisprudence," 
as  well  as  references  to  American  law  and  practice.     The  notes  of  the  former  editor,  Dr.  Harts- 
horne,  have  likewise  been  retained,  and  the  whole  is  presented  as  fully  worthy  to  maintain  the 
distinguished  position  which  the  work  has  acquired  as  a  leading  text-book  and  authority  on  the 
subject. 


A  Dew  edition  of  a  work  acknowledged  as  a  stand- 
ard authority  everywhere  within  the  range  of  the 
English  language.  Considering  the  new  matter  intro- 
duced, on  trichiniasis  and  other  subjects,  and  the 
plates  representing  the  crystals  of  poisons,  etc  ,  it  may 
fairly  be  regarded  as  the  most  compact,  comprehen- 
sive, and  practical  work  on  medical  jurisprudence 
which  has  issued  from  the  press,  and  the  one  best 
fitted  for  students. — Pacific  Med.  and  Surg.  Journal, 
Feb.  1867. 

The  sixth  edition  of  this  popular  work  comes  to  us 
In  charge  of  a  new  editor,  Mr.  Penrose,  of  the  Phila- 
delphia bar,  who  has  done  much  to  render  it  useful, 
not  only  to  the  medical  practitioners  of  this  country, 
but  to  those  of  his  own  profession.     Wisely  retaining 

the  references  of  the   former  American  editor.    Dr.  i  .  ,  .  ,    ,  ,  .      ,  . 

Hartshorne,  he  has  added  many  valuable  notes  of  his  :  ro"s  references  to  cases  which  have  occurred  in  this 
(jwn.  The  reputation  of  Dr.  Taylor's  work  is  so  well  i  country.  It  makes  thus  by  far  the  best  guide-book 
established,  that  it  needs  no  recommendation.  He  is  i  "i  this  departinent  of  medicine  for  stude^uts  and  the 
now  the  higliest  living  authority  on  all  matters  con-  i  general  practitioner  la  our  language.— i(«««y'/t  Mtd.  , 
nected  with  forensic  medicine,  and  every  successive  i  ^"*  Surg.  Journal,  Dec.  27,  Isbb. 
edition  of  his  valuable  work  gives  fresh  assurance  to  Taylor's  Medical  Jurisprudence  has  been  the  text- 
his  many  admirers  that  he  will  continue  to  maintain  book  in  our  colleges  for  years,  and  the  present  edi- 
his  well-earned  position.  No  one  should,  in  fact,  be  {  tion,  with  the  vi^luable  additions  made  by  the  Ameri- 
without  a  text-book  on  the  subject,  as  he  does  not  l  can  editor,  render  it  the  most  standard  work  of  the 
know  but  that  his  next  case  may  create  for  him  au  I  day,  on  the  peculiar  province  of  medicine  on  which 


elaborate  treatises. — New  York  Medical  Record,  Feb. 
15,  1SG7. 

The  present  edition  of  this  valuable  manual  is  a 
great  improvement  on  those  which  have  preceded  it. 
Some  admirable  instruction  on  the  subject  of  evidence 
and  the  duties  and  responsibilities  of  medical  wit- 
nesses has  been  added  by  the  distinguished  author, 
and  some  fifty  cuts,  illustrating  chietly  the  crystalline 
forms  and  microscopic  structure  of  substances  used 
as  poisons,  inserted.  The  American  editor  has  al.so 
introduced  several  chapters  from  Dr.  Taylor's  larger 
work,  "The  Principles  and  Practice  of  Medical  Juris- 
prudence," relating  to  trichiniasis,  sexual  malforma- 
tion, insanity  as  affecting  civil  responsibility,  suicidal 
mania,  and  life  insurance,  &c.,  which  add  considerably 
to  its  value.     Besides  this,  he  has  introduced  uume- 


emergency  for  its  use.  To  those  who  are  not  the  for- 
tunate possessors  of  a  reliable,  readable,  interesting, 
and  thoroughly  practical  work  upon  the  subject,  we 
would  earnestly  recommend  this,  as  forming  the  best 
groundwork  for  all  their  future  studies  of  the  more 


it  treats.  The  American  editor,  Dr.  Hartshorne,  has 
done  his  duty  to  the  text,  and,  upon  the  whole,  we 
caunot  but  consider  this  volume  the  best  and  richest 
treatise  on  medical  jurisprudence  in  our  language.— 
Brit.  Am.  Med.  Journal. 


W: 


INSLOW  {FORBES),  M.D.,  D.C.L.,  Sfc. 

ON  OBSCURE  DISEASES  OP  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  Engli.sh  edition.  In  one  handsome 
octavo  volume  of  nearly  §00  pages,  extra  cloth.     $4  25.     {Just  Issued.) 

our  conviction  that  it  is  long  since  so  iipportant  and 
beautifully  written  a  volume  has  issued  from  the 
British  medical  press.  The  details  of  the  manage- 
ment of  confirmed  cases  of  insanity  more  nearly  in- 
terest those  who  have  made  mental  diseases  their 
special  study;  but  Dr.  Winslow's  masterly  exposi- 
tion of  the  early  symptoms,  and  his  graphic  descrip 
tions  of  the  insidious  advances  of  incipient  insanity, 
together  with  his  judicious  observations  on  the  treat- 
ment of  disorders  of  the  mind,  should,  we  repeat,  be 
carefully  studied  by  all  who  have  undertaken  tli* 
responsibilities  of  medical  practice. — Dublin  Medical 
Press. 


Of  the  merits  of  Dr.  Winslow's  treatise  the  profe.s- 
eiou  has  sufficiently  judged.  It  has  taken  its  place  in 
the  front  rank  of  the  works  upon  the  special  depart- 
ment of  practical  medicine  to  which  it  pertains. — 
Oin' i aw iii  Journal  of  Medicine,  March,  IStiG. 

It  is  an  interesting  volume  that  will  amply  repay 
for  a  careful  perusal  by  all  intelligent  readers. — 
Chicago  Med.  Examiner,  Feb.  1866. 

A  work  whieh,  like  the  present,  will  largely  aid 
tlie  practitioner  in  recognizing  and  arresting  the  first 
in.sidious  advances  of  cerebral  and  mental  disease,  is 
one  of  immense  practical  value,  and  demands  earnest 
attention  and  diligent  study  on  the  part  of  all  who 
cave  embraced  the  medical  profession,  and  have 
Uiereby  undertaken  responsibilities  in  which  the 
welfare  and  happiness  of  individuals  and  families 
are  largely  involved.  We  shall  therefore  clow  this 
brief  and  necessarily  very  imperfect  notice  of  Dr. 
Winslow's  great  and  classical  work  by  expressing 


It  is  the  most  interesting  as  well  as  valuable  book 
that  we  have  seen  for  a  long  time.  It  is  truly  fasci- 
nating.— Am.  Jour.  Med.  Sciences. 

Dr.  Winslow's  work  will  undoubtedly  occupy  an 
unique  position  in  the  medico-psychological  litera- 
ture of  this  country. — London  Med.  Review. 


J  EA  {HENRY  C.) 

SUI'EUSTITTON    AND    FORCE:    ESS.WS    ON    THE   WAGER   OF 

LAW,  THE  AVAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     In  one  hand- 
some volume  royal  12ino.,  of  405  pages  ;  extra  cloth,  $2  60. 
The  copious  collection  of  facts  by  which  Mr.  I.ea  has  (  a  humor  so  fine  and  good,  that  he  makes  us  regret  It 


tUnstratod  his  subject  shows  in  the  fullest  manner  ihe 
consiiint  coiiHicl  and  varying  success,  the  advances 
"tMid  defeats,  by  which  the  progress  of  humane  legisla- 
tion has  been  and  is  still  marked.  This  work  lilts  up 
with  the  fullest  exempliflcatiou  and  detail  the  wise 
remarks  which  we  have  quoted  above.  As  a  book  of 
ready  reference  on  the  subject  it  is  of  the  highest 
value. —  Wesliiiinster  Revieto,  Oct.  1807. 


was  not  within  his  intent,  as  it  wns  certainly  within 
his  power,  to  render  the  whole  of  his  thorough  work 
more  popular  in  manner. — Atlantic  Monthly,  Feb.  '67. 
This  is  a  book  of  extraordinary  research.  Mr.  Lea 
h'hs  entered  into  his  subject  con  amore  ;  and  a  more 
striking  record  of  the  cruel  superstitions  of  our  un- 
happy Middle  Ages  could  not  possibly  have  been  com- 
piled. ...    As  a  work  of  curious  inquiry  on  certain 


When — half  in  spite  of  himself,  as  it  appears — he  |  outlying  points  of  obsolete  law,  "Superstition  and 
o^ketchesa  sceneor  character  in  tha  history  of  legalized  i  Force"  is  one  of  the  most  remarkable  books  we  have 
error  and  crualty,  ko  betrays  8oarti»tica  feeling,  niid  I  mui  with. — London  Atheiiaum,  Nov.  3,  1866. 


32 


Henry  C.  Lea's  Publications. 


INDEX    TO    CATALOGUE. 


Abel  and  Bloxam's  Handbook  of  Chemistry 
Allen's  Dissector  and  Practical  Anatomist 
American  Journal  of  the  Medical  Sciences 
Abstract,  Half-Yearly,  of  the  Med.  Sciences 
Anatomical  Atlas,  by  Smith  and  Horner 
Ashton  on  the  Kectum  and  Anus 
Ashwell  on  Diseases  of  Females 
Brinton  on  the  Stomach 
Barclay's  Medical  Diagnosis  . 
Barlow's  Practice  of  Medicine 
Barwell  on  the  Joints     . 
Bennet  (Henry)  on  Diseases  of  the  Tterns 
Bowman's  (John  E.)  Practical  Chemistry 
Bowman's  (John  E.)  Medical  Chemistry 
Brande  &  Taylor's  Chemistry 
Brodie's  Clinical  Lectures  on  Surgery  . 
Brown  on  the  Surgical  Diseases  of  Women 
Buckler  on  Bronchitis     .      '  . 
Bucknill  and  Tuke  on  Insanity      . 
Budd  on  Diseases  of  the  Liver 
Bumstead  on  Venereal    .... 
Bumstead  and  Cnllerier's  Atlas  of  Venereal 
Carpenter's  Human  Physiology    .        .  ■ 
Carpenter's  Comparative  Physiology   . 
Carpenter  on  the  Microscope 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Carson's  Synopsis  of  Materia  Medica    . 
Chambers  on  the  Indigestions 
Christison  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery  .  _     . 
Churchill  on  Diseases  of  Females 
Churchill  on  Puerperal  Fever 

Clymer  on  Fevers 

Colombat  de  I'lsere  on  Females,  by  Meigs 
Condie  on  Diseases  of  Children     . 
Cooper's  (B.  B.)  Lectures  on  Surgery    . 
CuUerier's  Atlas  of  Venereal  Diseases 
Curling  on  Diseases  of  the  Testis  . 
Cyclopedia  of  Practical  Medicine  . 
Daltoo's  Human  Physiology  . 
De  Jongh  on  Cod-Liver  Oil 
Dewees's  System  of  Midwifery 
Dewees  on  Diseases  of  Females 
Dewees  on  Diseases  of  Children    . 
Dickson's  Practice  of  Medicine 
Druitt's  Modern  Surgery 
Dunglison's  Medical  Dictionary    . 
Dunglison's  Human  Physiology    . 
Dunglison  on  New  Remedies 
Dunglison's  Therapeutics  and  Materia  Med 
Ellis's  Medical  Formulary,  by  Smith    . 
Erichsen's  System  of  Surgery 
Erichsen  on  Nervous  Injuries 
Flint  on  Respiratory  Organs  . 

Flint  on  the  Heart 

Flint's  Practice  of  Medicine  . 
Fownes's  Elementary  Chemistry  . 
Fuller  on   the  Lungs,  &c. 
Garduer's  Medical  Chemistry 

Gibson's  Surgery 

Gluge'8  Pathological  Histology,  by  Leidy 
Graham's  Elements  of  Chemistry  . 

Grav's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary  . 
Griffith's  (J.  W.)  Manual  on  the  Blood,  &c. 
Gross  on  Urinary  Organs 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross's  Principles  and  Practice  of  Surgery 
Gross's  Pathological  Anatomy 
Hartshorne's  Essentials  of  Medicine    . 
Habershon  on  Alimentary  Canal  . 
Hamilton  on  Dislocations  and  'ractures 
Harrison  on  the  Nervous  Systeri  . 
Hoblyn's  Medical  Dictionary 

Hodge  on  Women 

Hodge's  Obstetrics 

Hodge's  Practical  Dissections 

Holland's  Medical  Notes  and  Reflections 

Horner's  Anatomy  and  Histology 

Hudson  on  Fevers,  .... 

Hughes  on  Auscultation  and  Percnssion 

Hillier's  Handbook  of  Skin  Diseaies 

Jones's  ;T.  W.)  Ophthalmic  Medicine  and  Surg. 


PAGE 

11 

6 
1 
3 

6 
30 
22 
17 

16 
1.1 
2S 
22 
10 
10 
10 
2s 
22 
1,S 
18 
18 
19 
19 


Jones  and  Sieveking's  Pathological  Anatomy 

Jones  (C.  Handfleld;  on  Nervous  Disorders 

Kirkes'  Physiology         •.        .        .        . 

Knapp's  Chemical  Technology 

Lea's  Superstition  and  Force 

Lallemand  and  Wilson  on  Spermatorrhoja 

La  Roche  on  Yellow  Fever     . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye  .... 

Laycock  on  Medical  Observation  . 

Lelimann's  Physiological  Chemistry,  2  vols 

Lehmann's  Chemical  Physiology  . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever 

Maclise's  Surgical  Anatomy  . 

Malgaigne's  Operative  Surgery,  by  Brittan 

Marshall's  Physiology    .... 

Markwick's  Examination  of  Urine 

Mayue's  Dispensatory  and  Formulary 

Mackenzie  on  Diseases  of  the  Eye 

Medical  News  and  Library     . 

Meigs's  Obstetrics,  the  Science  and  the  Art 

Meigs's  Lectures  on  Diseases  of  Women 

Meigs  on  Puerperal  Fever 

Miller's  System  of  Obstetrics 

Miller's  Practice  of  Surgery  . 

Miller's  Principles  of  Surgery 

Montgomery  on  Pregnancy     . 

Modand  on  Urinary  Organs  . 

Morland  on  Uiiemia 

Neill  and  Smith's  Compendium  of  Med.  Science 

Neligan's  Atlas  of  Diseases  of  the  Skin 

Neligan  on  Diseases  of  the  Skin    . 

Prize  Essays  on  Consumption 

Parrish's  Practical  Pharmacy 

Peaslee's  Human  Histology    . 

Pirrie's  System  of  Surgery 


PABS 

14 


Pereira's  Mat.  Medica  and  Therapeutics,  abridged    13 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

Hanking's  Abstract  .... 

Roberts  on  Urinary  Diseases  . 

Ramsbotham  on  Parturition  . 

Reese  on  Blood  and  Urine      .        .        . 

Rigby  on  Female  Diseases 

Rigby's  Midwifery 

Rokilansky's  Pathological  Anatomy     . 
Royle's  Materia  Medica  and  Therapeutics 

Salter  on  Asthma 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Simon's  General  Pathology    . 

Simpson  on  Females        .... 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  on  Consumption  . 

Solly  on  Anatomy  and  Diseases  of  the  Braii 

Slill6's  Therapeutics        .... 

Tanner's  Manual  of  Clinical  Medicine  . 

Tanner  on  Pregnancy     .... 

Taylor's  Medical  Jurisprudence     . 

Thomas  on  Diseases  of  Females    . 

Toda  and  Bowman's  Physiological  Anatomy 

Todd  on  Acute  Diseases  .... 

Toynbee  on  the  Ear         .... 

Wales  on  Surgical  Operations 

Walshe  on  the  Heart      .... 

Watson's  Practice  of  Physic  . 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Ulceration  of  Os  Uteri 

What  to  Observe  in  Medical  Cases 

Williams's  Principles  of  Medicine 

Wilson's  Human  Anatomy    . 

Wilson's  Dissector 

Wilson  on  Diseases  of  the  Skin     . 
Wilson's  Plates  on  Diseases  •f  the  Skin 
Wilson's  Handbook  of  Cutaneous  Medicine 
Wilson  on  Healthy  Skin 
Wilson  on  Spermatorrlioja     .        •    '    • 
Winslow  on  Brain  and  Mind 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


NOHED  OCT  29  '63 


BIOMED  LIB. 

NOV  1 3  RECB 


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